Basic Information
| Provider Information | |||||||||
| NPI: | 1053372748 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIES-WAIT | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAIT | ||||||||
| OtherFirstName: | BRENDA | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 725 | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133260725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075476543 | ||||||||
| FaxNumber: | 6075473259 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 ATWELL RD | ||||||||
| Address2: | |||||||||
| City: | COOPERSTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 133261301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6075473259 | ||||||||
| FaxNumber: | 6075473259 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2006 | ||||||||
| LastUpdateDate: | 02/19/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 219178 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02215709 | 05 | NY | MEDICAID |