=====================================================
General NPI Number Information
=====================================================
NPI Number | 1962906115
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVENPORT HEALTH PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2018
-----------------------------------------------------
Last Update Date | 03/22/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1401 CHEROKEE DRIVE
-----------------------------------------------------
City | WAYCROSS
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 31501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-251-1644
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 56 W. MAIN STREET STE. 305
-----------------------------------------------------
City | CHRISTIANA
-----------------------------------------------------
State | DE
-----------------------------------------------------
Zip | 19702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 302-273-2247
-----------------------------------------------------
Fax | 302-533-6818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/PROVIDER
-----------------------------------------------------
Name | JEFFREY DAVENPORT
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 850-251-1644
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 63574
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------