Healthcare Provider Details

I. General information

NPI: 1982639621
Provider Name (Legal Business Name): JASON SCOTT DAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD
NORMAL IL
61761-6286
US

IV. Provider business mailing address

35 SUNSET RD
BLOOMINGTON IL
61701-2016
US

V. Phone/Fax

Practice location:
  • Phone: 309-664-3491
  • Fax:
Mailing address:
  • Phone: 309-452-1788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number281929
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD2018-0966
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number036101068
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: