=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659376952
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIE BOB DAVIS ME
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/15/2005
-----------------------------------------------------
Last Update Date | 04/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20333 W 151ST ST
-----------------------------------------------------
City | OLATHE
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66061-5350
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-791-4408
-----------------------------------------------------
Fax | 913-791-4438
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5800 FOXRIDGE DR STE 240
-----------------------------------------------------
City | MISSION
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66202-2338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-261-3153
-----------------------------------------------------
Fax | 913-262-3295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | KS 04-17213
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | MO R5059
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | R5059
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 04-17213
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 04-17213
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------