Healthcare Provider Details

I. General information

NPI: 1619009859
Provider Name (Legal Business Name): BRENT WADE DAVIS D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2007
Last Update Date: 07/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 W. 9 STREET
WELEETKA OK
74880-0337
US

IV. Provider business mailing address

PO BOX 207
HENRYETTA OK
74437-0207
US

V. Phone/Fax

Practice location:
  • Phone: 405-786-2248
  • Fax: 405-786-2006
Mailing address:
  • Phone: 405-786-2248
  • Fax: 405-786-2006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1913
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: