Healthcare Provider Details

I. General information

NPI: 1063168276
Provider Name (Legal Business Name): MR. DEITRON L DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2022
Last Update Date: 02/25/2022
Certification Date: 02/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MALCOLM X BLVD FRNT A
NEW YORK NY
10026-3021
US

IV. Provider business mailing address

1915 SEAGIRT BLVD APT 11L
FAR ROCKAWAY NY
11691-3786
US

V. Phone/Fax

Practice location:
  • Phone: 888-493-3488
  • Fax:
Mailing address:
  • Phone: 646-956-7916
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number591190737
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: