=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053914036
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LACY DAVIS MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2020
-----------------------------------------------------
Last Update Date | 11/20/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 195000 E COVELL RD
-----------------------------------------------------
City | LUTHER
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-513-1870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3418 PERSIMMON CREEK DR
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-7848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-513-1870
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, PHYSICIAN
-----------------------------------------------------
Name | DR. LACY STEPHENS DAVIS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 405-513-1870
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------