Healthcare Provider Details

I. General information

NPI: 1083408736
Provider Name (Legal Business Name): JOHN LAWRENCE DAVIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 S NEW BALLAS RD STE 3019B
SAINT LOUIS MO
63141-8267
US

IV. Provider business mailing address

621 S NEW BALLAS RD STE 3019B
SAINT LOUIS MO
63141-8267
US

V. Phone/Fax

Practice location:
  • Phone: 314-509-5305
  • Fax: 314-251-4454
Mailing address:
  • Phone: 314-509-5305
  • Fax: 314-251-4454

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2025025153
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: