Basic Information
| Provider Information | |||||||||
| NPI: | 1053302240 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1005 HEALTH CENTER DR STE 201 | ||||||||
| Address2: | |||||||||
| City: | MATTOON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 619384693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2172386055 | ||||||||
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| Practice Location | |||||||||
| Address1: | 890 E RIDGELAWN RD | ||||||||
| Address2: | |||||||||
| City: | MARTINSVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 624422551 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2173824191 | ||||||||
| FaxNumber: | 2173824248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 10/25/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01039458A | IN | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 036086811 | IL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 006686 | 01 | IL | HEALTH ALLIANCE | OTHER | 311661293 | 01 | IL | HEALTH LINK | OTHER | 0004400750 | 01 | IL | AETNA | OTHER | 311661293 | 01 | IL | PERSONAL CARE | OTHER | 311661293001 | 05 | IL | MEDICAID | 000000079566 | 01 | IN | ANTHEM BLUE CROSS | OTHER | 01225376 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |