Healthcare Provider Details

I. General information

NPI: 1568666121
Provider Name (Legal Business Name): JUSTIN MARK DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 N PORTLAND AVE
OKLAHOMA CITY OK
73112-2074
US

IV. Provider business mailing address

PO BOX 248875 SUITE 300
OKLAHOMA CITY OK
73124-8875
US

V. Phone/Fax

Practice location:
  • Phone: 405-604-6000
  • Fax:
Mailing address:
  • Phone: 918-392-2944
  • Fax: 918-664-2521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberBP1-0026250
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number27437
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: