Basic Information
| Provider Information | |||||||||
| NPI: | 1376126417 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 829 CAMP ST | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462023049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7653091037 | ||||||||
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| Practice Location | |||||||||
| Address1: | UNC MEDICAL CENTER | ||||||||
| Address2: | 101 MANNING DRIVE | ||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 27514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9849741000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2021 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | DAVI-6UVG6T | NC | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.