Basic Information
| Provider Information | |||||||||
| NPI: | 1437160546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | REGINA | ||||||||
| MiddleName: | DENISE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3960 TURNPIKE ROAD | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL CENTER VICTORY, LLC | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573931136 | ||||||||
| FaxNumber: | 7573935534 | ||||||||
| Practice Location | |||||||||
| Address1: | 3960 TURNPIKE ROAD | ||||||||
| Address2: | JENCARE NEIGHBORHOOD MEDICAL CENTER VICTORY, LLC | ||||||||
| City: | PORTSMOUTH | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573931136 | ||||||||
| FaxNumber: | 7573935534 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 10/10/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101049715 | VA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 005630339 | 05 | VA | MEDICAID |