Healthcare Provider Details

I. General information

NPI: 1295703122
Provider Name (Legal Business Name): KENNETH DAVIS JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 03/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN STREET
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

PO BOX 636256 CENTRAL CREDENTIALING
CINCINNATI OH
45263-6256
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8787
  • Fax: 513-558-3136
Mailing address:
  • Phone: 513-585-5506
  • Fax: 513-585-5511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number35 051087
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number35-051087
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: