Healthcare Provider Details

I. General information

NPI: 1285600668
Provider Name (Legal Business Name): LARRY J DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6901 MEDICAL PARKWAY
WACO TX
76712
US

IV. Provider business mailing address

PO BOX 674047
DALLAS TX
75267
US

V. Phone/Fax

Practice location:
  • Phone: 254-582-7481
  • Fax: 254-582-2199
Mailing address:
  • Phone: 254-582-7481
  • Fax: 254-582-2199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License NumberC15087
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: