Healthcare Provider Details

I. General information

NPI: 1174583405
Provider Name (Legal Business Name): THOMAS A DAVENPORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

999 FRANKLIN AVE
GARDEN CITY NY
11530-2913
US

IV. Provider business mailing address

999 FRANKLIN AVE
GARDEN CITY NY
11530-2913
US

V. Phone/Fax

Practice location:
  • Phone: 516-742-3404
  • Fax: 516-294-6942
Mailing address:
  • Phone: 516-742-3404
  • Fax: 516-294-6942

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number214557
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: