Healthcare Provider Details

I. General information

NPI: 1588662050
Provider Name (Legal Business Name): JASON DAVIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 02/22/2023
Certification Date: 02/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3940 N MARQUETTE ST
DAVENPORT IA
52806-4430
US

IV. Provider business mailing address

3940 N MARQUETTE ST
DAVENPORT IA
52806-4430
US

V. Phone/Fax

Practice location:
  • Phone: 563-386-3111
  • Fax: 563-386-3113
Mailing address:
  • Phone: 563-386-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberIA3392
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: