Healthcare Provider Details

I. General information

NPI: 1780046730
Provider Name (Legal Business Name): MARIAH DAVIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAH GAWLIK

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CAPEHART RD
OFFUTT AFB NE
68113-1043
US

IV. Provider business mailing address

2501 CAPEHART RD
OFFUTT AFB NE
68113-1043
US

V. Phone/Fax

Practice location:
  • Phone: 402-294-6077
  • Fax:
Mailing address:
  • Phone: 402-294-6077
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2018003022
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number32054
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: