=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972611556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRAIG MATTHEW DAVIS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/25/2006
-----------------------------------------------------
Last Update Date | 07/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8440 W LAKE MEAD BLVD SUITE 104
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-7648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-489-4838
-----------------------------------------------------
Fax | 702-489-4837
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8440 W LAKE MEAD BLVD SUITE 104
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-7648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-489-4838
-----------------------------------------------------
Fax | 702-489-4837
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number | 23337
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 23337
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 4820
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number | 10713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | 10713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 10713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 207NS0135X
-----------------------------------------------------
Taxonomy Name | Procedural Dermatology Physician
-----------------------------------------------------
License Number | 10713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 10713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | 10713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 31661
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 207ND0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology Physician
-----------------------------------------------------
License Number | 31661
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 207ZD0900X
-----------------------------------------------------
Taxonomy Name | Dermatopathology (Pathology) Physician
-----------------------------------------------------
License Number | 31661
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #13
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | 31661
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #14
-----------------------------------------------------
Taxonomy Code | 207ND0101X
-----------------------------------------------------
Taxonomy Name | MOHS-Micrographic Surgery Physician
-----------------------------------------------------
License Number | 31661
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #15
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | 10713
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------