Provider Demographics
NPI:1174604987
Name:DAVIS, ROGER (PHD)
Entity type:Individual
Prefix:MR
First Name:ROGER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6817 SOUTHPOINT PKWY STE 904
Mailing Address - Street 2:904
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6293
Mailing Address - Country:US
Mailing Address - Phone:904-332-9100
Mailing Address - Fax:904-482-0647
Practice Address - Street 1:6817 SOUTHPOINT PKWY STE 904
Practice Address - Street 2:904
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-6293
Practice Address - Country:US
Practice Address - Phone:904-332-9100
Practice Address - Fax:904-482-0647
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 5281103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL59891Medicare ID - Type UnspecifiedPSYCHOLOGIST