Healthcare Provider Details

I. General information

NPI: 1629282496
Provider Name (Legal Business Name): JUSTIN R DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 01/20/2025
Certification Date: 01/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 CHILDRENS AVE
OKLAHOMA CITY OK
73104-4637
US

IV. Provider business mailing address

2500 N STATE ST
JACKSON MS
39216-4500
US

V. Phone/Fax

Practice location:
  • Phone: 405-271-2429
  • Fax:
Mailing address:
  • Phone: 601-984-2195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2012004798
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number04-35493
License Number StateKS
# 3
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number23806
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License NumberR4957
License Number StateTX
# 5
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number44055
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: