Basic Information
| Provider Information | |||||||||
| NPI: | 1659376952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | WILLIE | ||||||||
| MiddleName: | BOB | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5800 FOXRIDGE DR | ||||||||
| Address2: | STE 240 | ||||||||
| City: | MISSION | ||||||||
| State: | KS | ||||||||
| PostalCode: | 662022338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9132613153 | ||||||||
| FaxNumber: | 9132623295 | ||||||||
| Practice Location | |||||||||
| Address1: | 20333 W 151ST ST | ||||||||
| Address2: | |||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660615350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137914408 | ||||||||
| FaxNumber: | 9137914438 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 04/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | KS 04-17213 | KS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MO R5059 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 2085R0202X | R5059 | MO | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 208D00000X | 04-17213 | KS | N | Allopathic & Osteopathic Physicians | General Practice | 2085R0202X | 04-17213 | KS | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 201018322 | 05 | MO | MEDICAID | 10001780C | 05 | KS | MEDICAID |