Healthcare Provider Details

I. General information

NPI: 1699766998
Provider Name (Legal Business Name): JOHN EVAN DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 02/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CLINIC DR
RICHLANDS VA
24641-1102
US

IV. Provider business mailing address

PO BOX CVPA
RICHLANDS VA
24641-1102
US

V. Phone/Fax

Practice location:
  • Phone: 276-964-6771
  • Fax: 276-964-1314
Mailing address:
  • Phone: 276-964-6771
  • Fax: 276-964-1314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101031673
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: