Provider Demographics
NPI:1023488392
Name:DAVIS, CLANCY
Entity type:Individual
Prefix:
First Name:CLANCY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 SOUTH BROADWAY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-0000
Mailing Address - Country:US
Mailing Address - Phone:580-332-3001
Mailing Address - Fax:580-332-8774
Practice Address - Street 1:124 SOUTH BROADWAY
Practice Address - Street 2:SUITE 200
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-0000
Practice Address - Country:US
Practice Address - Phone:580-332-3001
Practice Address - Fax:580-332-8774
Is Sole Proprietor?:No
Enumeration Date:2015-09-30
Last Update Date:2015-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist