Healthcare Provider Details

I. General information

NPI: 1952391401
Provider Name (Legal Business Name): WILLIAM WAYNE DAVENPORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2005
Last Update Date: 03/07/2023
Certification Date: 09/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

582 ISLAND WALK E
MT PLEASANT SC
29464-7834
US

IV. Provider business mailing address

582 ISLAND WALK E
MT PLEASANT SC
29464-7834
US

V. Phone/Fax

Practice location:
  • Phone: 501-815-4924
  • Fax:
Mailing address:
  • Phone: 501-815-4924
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberE-4365
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberE4365
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberE-4365
License Number StateAR
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number76325
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: