Basic Information
| Provider Information | |||||||||
| NPI: | 1962710780 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | DEMETRICE | ||||||||
| MiddleName: | SHARNAE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3186 S MARYLAND PKWY | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891092317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029424123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7130 SMOKE RANCH RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891283157 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029424117 | ||||||||
| FaxNumber: | 8649871611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2010 | ||||||||
| LastUpdateDate: | 09/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 14415 | NV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | P00113844 | 01 | NV | RR MEDICARE | OTHER | 1962710780 | 05 | NV | MEDICAID |