Basic Information
| Provider Information | |||||||||
| NPI: | 1174511919 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | GREGORY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 140349 | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995140349 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077927920 | ||||||||
| FaxNumber: | 9077927901 | ||||||||
| Practice Location | |||||||||
| Address1: | 2751 DEBARR RD | ||||||||
| Address2: | SUITE 390 | ||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995082952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077927920 | ||||||||
| FaxNumber: | 9077927901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2005 | ||||||||
| LastUpdateDate: | 02/05/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | E1817 | AR | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 2085R0202X | 6038 | AK | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 141610001 | 05 | AR | MEDICAID |