Healthcare Provider Details

I. General information

NPI: 1679756027
Provider Name (Legal Business Name): BJ DAVIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 12/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3804 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1081
US

IV. Provider business mailing address

3804 MONTGOMERY BLVD NE
ALBUQUERQUE NM
87109-1081
US

V. Phone/Fax

Practice location:
  • Phone: 505-883-8099
  • Fax: 505-883-8060
Mailing address:
  • Phone: 505-883-8099
  • Fax: 505-883-8060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA40958
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: