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NPI Code Detail

MEDICARE: DR. JOHN MATTISON DAVIS M.D.

MEDICARE: DR. JOHN MATTISON DAVIS M.D.
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
12084A0401XAddiction Medicine (Psychiatry & Neurology) Physician0101264206VA
22084P0800XPsychiatry Physician0101264206VA

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2P00872494OTHERKYRR MEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1700857620
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. JOHN MATTISON DAVIS M.D.
Provider Business Mailing Address
First Line : 680 STEWART AVE
Second Line :
City : SAINT PAUL
State : MN
Zip : 55102-4117
Country : US
Telephone Number : 800-257-7800
Fax Number :
Provider Business Practice Location Address
First Line : 680 STEWART AVE
Second Line :
City : SAINT PAUL
State : MN
Zip : 55102-4117
Country : US
Telephone Number : 800-257-7800
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/30/2006
Last Update Date : 06/15/2026

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