Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | 0101057082 | VA |
Y | 2081P2900X | Pain Medicine | D0066221 | MD |
NPI | 1235120684 |
---|---|
Provider Name | Dr. Shelton Avery Davis |
First Address | Hagerstown, MD 21740-5471 |
Second Address | Hagerstown, MD 21740-5471 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 03/11/2005 |
Last Update Date | 01/07/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
312202600 | (05) | MD |
96386101 | BCBS LOCAL CAREFIRST KG85 (01) | MD |
P00854251 | RR MEDICARE MD (01) | MD |
VAD000 | (02) | |
W2660027 | BCBS REGIONAL W266 (01) | MD |