Healthcare Provider Details

I. General information

NPI: 1588649891
Provider Name (Legal Business Name): JOHN B DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/08/2005
Last Update Date: 03/07/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 EXCHANGE ST W #750
SAINT PAUL MN
55102-1045
US

IV. Provider business mailing address

17 EXCHANGE ST W #750
SAINT PAUL MN
55102-1045
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-4340
  • Fax: 651-232-4198
Mailing address:
  • Phone: 651-232-4340
  • Fax: 651-232-4198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number46186
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: