Healthcare Provider Details

I. General information

NPI: 1417044538
Provider Name (Legal Business Name): RICHARD A DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2006
Last Update Date: 02/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 S MAPLE ST STE 200
WACONIA MN
55387-1757
US

IV. Provider business mailing address

8170 33RD AVE S MS21110Q
MINNEAPOLIS MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-442-2163
  • Fax: 952-442-5903
Mailing address:
  • Phone: 952-883-5375
  • Fax: 651-254-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number53307
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: