Healthcare Provider Details

I. General information

NPI: 1861502783
Provider Name (Legal Business Name): JASON L DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/20/2022
Certification Date: 01/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 FITZSIMMONS DR
JOINT BASE LEWIS MCCHORD WA
98431-1000
US

IV. Provider business mailing address

1501 NE MEDICAL CENTER DR
BEND OR
97701-6051
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-3229
  • Fax: 253-968-0100
Mailing address:
  • Phone: 541-382-4900
  • Fax: 541-706-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD207771
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD00046375
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberL0784
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: