Basic Information
| Provider Information | |||||||||
| NPI: | 1639152978 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | KIRK | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4235 SECOR RD | ||||||||
| Address2: | |||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194739500 | ||||||||
| FaxNumber: | 4194739501 | ||||||||
| Practice Location | |||||||||
| Address1: | 4126 N HOLLAND SYLVANIA ROAD | ||||||||
| Address2: | 100 | ||||||||
| City: | TOLEDO | ||||||||
| State: | OH | ||||||||
| PostalCode: | 43623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4194739500 | ||||||||
| FaxNumber: | 4194739501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2005 | ||||||||
| LastUpdateDate: | 05/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 34-005964 | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 34005964 | OH | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 200044047 | 01 | OH | RAILROAD MEDICARE | OTHER | 2139340 | 05 | OH | MEDICAID |