Healthcare Provider Details

I. General information

NPI: 1467583393
Provider Name (Legal Business Name): CARL SPENCER DAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

801 NE ANDERSON LN
LEES SUMMIT MO
64064-1244
US

IV. Provider business mailing address

3509 NW WINDING WOODS DR
LEES SUMMIT MO
64064-1879
US

V. Phone/Fax

Practice location:
  • Phone: 816-478-3700
  • Fax: 816-478-3640
Mailing address:
  • Phone: 816-350-3603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR9105
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: