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General NPI Number Information
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NPI Number | 1003935453
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Entity Type | Individual
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Provider Name | JERRY M. DAVENPORT D. O.
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Gender | Male
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Dates
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Enumeration Date | 03/28/2007
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Last Update Date | 01/26/2011
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Provider Practice Location Address
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Address Line | 306 W 5TH AVE NORTON SOUND HEALTH COOPERATION
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City | NOME
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State | AK
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Zip | 99762
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Country | US
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Telephone | 907-443-3214
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Fax |
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Provider Business Mailing Address
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Address Line | 9223 STONE RIDGE CIR
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City | SANDY
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State | UT
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Zip | 84093-2698
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Country | US
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Telephone | 801-944-1335
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Fax | 801-944-1335
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 4105
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License Number State | AK
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