Healthcare Provider Details

I. General information

NPI: 1851373674
Provider Name (Legal Business Name): CHARLES W. DAVENPORT JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 11/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 12TH ST
MERIDIAN MS
39301-4158
US

IV. Provider business mailing address

1800 12TH ST
MERIDIAN MS
39301-4158
US

V. Phone/Fax

Practice location:
  • Phone: 601-703-4065
  • Fax: 601-703-3050
Mailing address:
  • Phone: 601-703-9506
  • Fax: 601-703-3264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number13521
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: