Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | 01072503A | IN |
NPI | 1053549139 |
---|---|
Provider Name | Jon C Davis |
First Address | Evansville, IN 47737-3868 |
Second Address | Evansville, IN 47713-1227 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/06/2009 |
Last Update Date | 16/07/2013 |