Basic Information
| Provider Information | |||||||||
| NPI: | 1942232699 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | DUANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2415 N ORANGE AVE | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328045505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073032474 | ||||||||
| FaxNumber: | 4073030678 | ||||||||
| Practice Location | |||||||||
| Address1: | 2415 N ORANGE AVE | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 328045505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4073032474 | ||||||||
| FaxNumber: | 4073030678 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 10/16/2015 | ||||||||
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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 | 208600000X | 35313 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 208G00000X | 35313 | NC | N | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | 208G00000X | 0101240959 | VA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 8927722 | 05 | NC | MEDICAID |