Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213ES0131X | Foot Surgery | 105902-0501 | UT |
NPI | 1225104250 |
---|---|
Provider Name | Dr. Jack M Davis |
First Address | Farr West, UT 84404-9586 |
Second Address | Farr West, UT 84404-9586 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2006 |
Last Update Date | 08/07/2007 |