Healthcare Provider Details

I. General information

NPI: 1063040590
Provider Name (Legal Business Name): JONATHON SAMUEL DAVIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/23/2025
Certification Date: 07/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 N HILLSIDE ST
WICHITA KS
67214-4976
US

IV. Provider business mailing address

4443 N GREY MEADOWS ST
MAIZE KS
67101-5200
US

V. Phone/Fax

Practice location:
  • Phone: 503-413-7074
  • Fax: 503-413-6892
Mailing address:
  • Phone: 515-297-1491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License Number05-50922
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: