Provider Demographics
NPI:1730159666
Name:DAVIS, SAMUEL M (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:M
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 1:277 ALL SKY DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80921-2886
Mailing Address - Country:US
Mailing Address - Phone:937-974-3407
Mailing Address - Fax:
Practice Address - Street 1:4102 PINION DR
Practice Address - Street 2:SUITE 100
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840-2502
Practice Address - Country:US
Practice Address - Phone:719-333-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2009-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-085824207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000371925OtherBLUECROSS BLUESHIELD
I36945Medicare UPIN
OH000000371925OtherBLUECROSS BLUESHIELD