Basic Information
| Provider Information | |||||||||
| NPI: | 1346484581 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W | ||||||||
| Address2: | ATTN. CREDENTIALING | ||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 4095 E PONY EXPRESS PKWY STE 1 | ||||||||
| Address2: | |||||||||
| City: | EAGLE MOUNTAIN | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840055531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8014298037 | ||||||||
| FaxNumber: | 8017537476 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2009 | ||||||||
| LastUpdateDate: | 06/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 11327523-1205 | UT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | MD162235 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | MD162235 | OR | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 11327523-1205 | UT | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1346484581 | 01 | NPI | OTHER | 500659989 | 05 | OR | MEDICAID |