Provider Demographics
NPI:1902935778
Name:DAVIS, TERRY D'WAYNE
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:D'WAYNE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3816 PIEDMONT RD
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76116-9413
Mailing Address - Country:US
Mailing Address - Phone:214-679-6596
Mailing Address - Fax:
Practice Address - Street 1:3816 PIEDMONT RD
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76116
Practice Address - Country:US
Practice Address - Phone:817-731-3440
Practice Address - Fax:817-731-0212
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes333300000XSuppliersEmergency Response System Companies
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXD001015012Medicaid