Healthcare Provider Details

I. General information

NPI: 1780619635
Provider Name (Legal Business Name): MICHAEL RAY DAVENPORT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1049 E 46TH ST
CHICAGO IL
60653-3618
US

IV. Provider business mailing address

2320 E 93RD ST
CHICAGO IL
60617-3983
US

V. Phone/Fax

Practice location:
  • Phone: 773-285-5902
  • Fax: 773-285-1717
Mailing address:
  • Phone: 773-967-5002
  • Fax: 773-967-4191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: