Basic Information
| Provider Information | |||||||||
| NPI: | 1679533665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | RICHARD | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 WALNUT ST | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | LEMOYNE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170431168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177610208 | ||||||||
| FaxNumber: | 7177612023 | ||||||||
| Practice Location | |||||||||
| Address1: | 4470 VALLEY ST | ||||||||
| Address2: | |||||||||
| City: | ENOLA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 170251443 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177328883 | ||||||||
| FaxNumber: | 7177321640 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 08/18/2009 | ||||||||
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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 | 207Q00000X | MD032778E | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 068548 | 05 | PA | MEDICAID |