Healthcare Provider Details

I. General information

NPI: 1063414480
Provider Name (Legal Business Name): JEFFREY TODD DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2005
Last Update Date: 05/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

568 S CLEVELAND AVE STE B
WESTERVILLE OH
43081
US

IV. Provider business mailing address

568 S CLEVELAND AVE STE B
WESTERVILLE OH
43081-8970
US

V. Phone/Fax

Practice location:
  • Phone: 614-895-3344
  • Fax: 614-895-3795
Mailing address:
  • Phone: 614-895-3344
  • Fax: 614-895-3795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number30501
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number35.120017
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: