Healthcare Provider Details

I. General information

NPI: 1790722437
Provider Name (Legal Business Name): NEVILLE DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 W EDGEWOOD DR STE D
JEFFERSON CITY MO
65109-5869
US

IV. Provider business mailing address

PO BOX 1027
JEFFERSON CITY MO
65102-1027
US

V. Phone/Fax

Practice location:
  • Phone: 573-761-2121
  • Fax: 573-635-0726
Mailing address:
  • Phone: 573-761-7246
  • Fax: 573-761-6947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberR4P82
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR4P82
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: