Basic Information
| Provider Information | |||||||||
| NPI: | 1346228921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | ISAAC | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36123 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136601616 | ||||||||
| FaxNumber: | 9136601664 | ||||||||
| Practice Location | |||||||||
| Address1: | 1615 PARKER AVE | ||||||||
| Address2: | |||||||||
| City: | OSAWATOMIE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660641703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9136601616 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/04/2006 | ||||||||
| LastUpdateDate: | 04/06/2018 | ||||||||
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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 | 207RG0300X | 2006018665 | MO | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | 0429493 | KS | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
No ID Information.