Basic Information
| Provider Information | |||||||||
| NPI: | 1316112089 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | BARRY | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3461 FAIRLANE FARMS RD | ||||||||
| Address2: | |||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334148752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617661300 | ||||||||
| FaxNumber: | 5616930539 | ||||||||
| Practice Location | |||||||||
| Address1: | 241 SE 1ST ST | ||||||||
| Address2: | |||||||||
| City: | BELLE GLADE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334303501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617079149 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2008 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | ME123475 | FL | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1316112089 | 05 | NC | MEDICAID | NC2668 | 05 | SC | MEDICAID |