Basic Information
| Provider Information | |||||||||
| NPI: | 1568472785 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | ELAINE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3075 N RESERVE ST | ||||||||
| Address2: | SUITE Q | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063271850 | ||||||||
| FaxNumber: | 4063271875 | ||||||||
| Practice Location | |||||||||
| Address1: | 3075 N RESERVE ST | ||||||||
| Address2: | SUITE Q | ||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081389 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063271850 | ||||||||
| FaxNumber: | 4063271875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2006 | ||||||||
| LastUpdateDate: | 03/23/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MT7595 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | MT7595 | MT | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 000007801 | 01 | MT | BCBS | OTHER | 0104286 | 05 | MT | MEDICAID |