MEDICARE: JOHN G DAVENPORT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084N0400X	Neurology Physician	29542	MN

General Provider Information

NPI Number	:	1205810488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN G DAVENPORT

Provider Business Mailing Address
First Line	:	6465 WAYZATA BLVD
Second Line	:	SUITE 315
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-1728
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6490 EXCELSIOR BLVD
Second Line	:	SUITE E500
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55426-4705
Country	:	US
Telephone Number	:	952-993-7342
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2005
Last Update Date	:	07/08/2007

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