Basic Information
| Provider Information | |||||||||
| NPI: | 1578790473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | MARK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O BOX 1205 | ||||||||
| Address2: | |||||||||
| City: | CENTER POINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8302857881 | ||||||||
| FaxNumber: | 6023233496 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 MESA VERDE DR. | ||||||||
| Address2: | |||||||||
| City: | CENTER POINT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306342212 | ||||||||
| FaxNumber: | 8306347820 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2009 | ||||||||
| LastUpdateDate: | 07/08/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5634 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | N7611 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 620864 | 05 | AZ | MEDICAID |