=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811999063
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RICHARD D DAVENPORT MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/01/2005
-----------------------------------------------------
Last Update Date | 12/03/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2424 S 90TH ST STE 506
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-328-8760
-----------------------------------------------------
Fax | 414-328-8763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2424 S 90TH ST STE 506
-----------------------------------------------------
City | WEST ALLIS
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53227-2455
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 414-328-8760
-----------------------------------------------------
Fax | 414-328-8763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 19876
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------