Healthcare Provider Details

I. General information

NPI: 1558384511
Provider Name (Legal Business Name): JESSICA A DAVIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 HUDSON AVENUE SUITE 2
STILLWATER NY
12170
US

IV. Provider business mailing address

PO BOX 173 781 HUDSON AVE, SUITE 2
STILLWATER NY
12170-0173
US

V. Phone/Fax

Practice location:
  • Phone: 518-664-6116
  • Fax: 866-874-7242
Mailing address:
  • Phone: 518-664-6116
  • Fax: 866-874-7242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number247491
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: