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General NPI Number Information
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NPI Number | 1063168276
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Entity Type | Individual
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Provider Name | MR. DEITRON L DAVIS
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Gender | Male
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Dates
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Enumeration Date | 02/25/2022
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Last Update Date | 02/25/2022
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Provider Practice Location Address
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Address Line | 55 MALCOLM X BLVD FRNT A
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City | NEW YORK
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State | NY
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Zip | 10026-3021
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Country | US
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Telephone | 888-493-3488
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Fax |
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Provider Business Mailing Address
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Address Line | 1915 SEAGIRT BLVD APT 11L
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City | FAR ROCKAWAY
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State | NY
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Zip | 11691-3786
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Country | US
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Telephone | 646-956-7916
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Fax |
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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 | 172A00000X
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Taxonomy Name | Driver
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License Number | 591190737
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License Number State | NY
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