=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346275443
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD DAVIS MD, FACS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2006
-----------------------------------------------------
Last Update Date | 06/19/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1951 SW 172ND AVE SUITE 205
-----------------------------------------------------
City | MIRAMAR
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33029-5593
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-442-5191
-----------------------------------------------------
Fax | 786-228-2853
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2504 EAGLE RUN DR
-----------------------------------------------------
City | WESTON
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33327-1427
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-389-9447
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207YX0905X
-----------------------------------------------------
Taxonomy Name | Otolaryngology/Facial Plastic Surgery Physician
-----------------------------------------------------
License Number | ME64358
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------