Healthcare Provider Details

I. General information

NPI: 1639425754
Provider Name (Legal Business Name): BRYAN F DAVIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2012
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 KINGS WAY E STE B1
SEWELL NJ
08080-2237
US

IV. Provider business mailing address

1A REGULUS DR
TURNERSVILLE NJ
08012-2427
US

V. Phone/Fax

Practice location:
  • Phone: 856-536-1515
  • Fax: 856-412-5324
Mailing address:
  • Phone: 844-542-2273
  • Fax: 856-256-7518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0000004846
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number325394
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25MB09665900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: