Provider Demographics
NPI:1205874013
Name:DAVIS, JOHN S (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:S
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5590 KIETZKE LN
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-3019
Mailing Address - Country:US
Mailing Address - Phone:775-323-2080
Mailing Address - Fax:775-325-2334
Practice Address - Street 1:5590 KIETZKE LN
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-3019
Practice Address - Country:US
Practice Address - Phone:775-323-2080
Practice Address - Fax:775-325-2334
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2018-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV4127207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV880167036A011OtherTRICARE
CAXPY001350Medicaid
NV002016378Medicaid
NVCC4127OtherBLUE CROSS BLUE SHIELD
NV880167036A011OtherTRICARE
CAXPY001350Medicaid
NVV14WCGZF02Medicare PIN