MEDICARE: JERRY T. DAVIS D.O.,P.A.

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	207Q00000X	Family Medicine Physician	F9351	TX

General Provider Information

NPI Number	:	1215217229
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JERRY T. DAVIS D.O.,P.A.

Provider Business Mailing Address
First Line	:	6302 JACKSBORO HWY STE A
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-3607
Country	:	US
Telephone Number	:	817-237-8273
Fax Number	:	817-237-0374

Provider Business Practice Location Address
First Line	:	6302 JACKSBORO HWY STE A
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76135-3607
Country	:	US
Telephone Number	:	817-237-8273
Fax Number	:	817-237-0374

Authorized Official
Title or Position	:	MANAGER
Name	:	MS. GLENDA WRIGHT
Credential	:
Telephone Number	:	817-237-8273

Provider Enumeration Date	:	08/22/2011
Last Update Date	:	10/17/2011

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