Provider Demographics
NPI:1902148273
Name:DAVENPORT, KATHLEEN PATRICIA THERESA (MD)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:PATRICIA THERESA
Last Name:DAVENPORT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 PARKMAN ST
Mailing Address - Street 2:APARTMENT 3
Mailing Address - City:BROOKLINE
Mailing Address - State:MA
Mailing Address - Zip Code:02446-7043
Mailing Address - Country:US
Mailing Address - Phone:703-887-6444
Mailing Address - Fax:
Practice Address - Street 1:71 PARKMAN ST
Practice Address - Street 2:APT 3
Practice Address - City:BROOKLINE
Practice Address - State:MA
Practice Address - Zip Code:02446-7043
Practice Address - Country:US
Practice Address - Phone:703-887-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-25
Last Update Date:2017-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MA255964207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program