Healthcare Provider Details

I. General information

NPI: 1063459824
Provider Name (Legal Business Name): WAYNE L. DAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 01/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 W BROADWAY ST
MISSOULA MT
59802-4003
US

IV. Provider business mailing address

3205 S RUSSELL ST
MISSOULA MT
59801-8536
US

V. Phone/Fax

Practice location:
  • Phone: 406-543-7271
  • Fax:
Mailing address:
  • Phone: 406-721-4906
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number7721
License Number StateMT
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number7721
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: