Healthcare Provider Details

I. General information

NPI: 1649230525
Provider Name (Legal Business Name): LEAMON L. DAVENPORT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 05/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 MEDICAL CENTER BLVD SUITE 205
UPLAND PA
19013-3955
US

IV. Provider business mailing address

30 MEDICAL CENTER BLVD SUITE 205
UPLAND PA
19013-3955
US

V. Phone/Fax

Practice location:
  • Phone: 610-619-7410
  • Fax: 610-876-8483
Mailing address:
  • Phone: 610-619-7410
  • Fax: 610-876-8483

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMB08546500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA123303
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS017399
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberMB08546500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier43670083
Identifier TypeMEDICAID
Identifier StateNM
Identifier Issuer
# 2
Identifier807919
Identifier TypeMEDICAID
Identifier StateAZ
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: