Provider Demographics
NPI:1528238201
Name:CHRISTOPHER DAVENPORT MD MBA PA
Entity type:Organization
Organization Name:CHRISTOPHER DAVENPORT MD MBA PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:VERNON
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:863-646-9600
Mailing Address - Street 1:207 PALMOLA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33803-2242
Mailing Address - Country:US
Mailing Address - Phone:863-646-9600
Mailing Address - Fax:330-422-6245
Practice Address - Street 1:207 PALMOLA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-2242
Practice Address - Country:US
Practice Address - Phone:863-646-9600
Practice Address - Fax:330-422-6245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00875962084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK4791Medicare PIN