Basic Information
| Provider Information | |||||||||
| NPI: | 1194085902 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVISSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | LAWRENCE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 485 | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473620485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655210890 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 N 16TH ST | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 473624319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7655210890 | ||||||||
| FaxNumber: | 7655211555 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2012 | ||||||||
| LastUpdateDate: | 09/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 09/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 48216 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 01077390A | IN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201377670 | 05 | IN | MEDICAID | P01723965 | 01 | IN | RR MEDICARE | OTHER |