Healthcare Provider Details

I. General information

NPI: 1184746869
Provider Name (Legal Business Name): JAMES LEE DAVENPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

306 PINE HILL RD
ELIZABETHTON TN
37643-2920
US

IV. Provider business mailing address

306 PINE HILL RD
ELIZABETHTON TN
37643-2920
US

V. Phone/Fax

Practice location:
  • Phone: 423-542-4189
  • Fax: 423-542-4181
Mailing address:
  • Phone: 423-542-4189
  • Fax: 423-542-4181

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number34068
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number36009
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number36009
License Number StateTN

VIII. Authorized Official

Name: DR. JAMES LEE DAVENPORT
Title or Position: OWNER
Credential: M.D.
Phone: 423-542-4189