=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578875191
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JILL DAVENPORT, MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2010
-----------------------------------------------------
Last Update Date | 07/14/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7808 CLODUS FIELDS DR
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75251-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-558-9585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6823 CORONADO AVE
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75214-4015
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-558-9585
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | JILL DAVENPORT
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 214-558-9585
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | M4021
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------