Provider Demographics
NPI:1255351367
Name:DAVIS, RONALD D (MD)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:D
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:971 LAKELAND DR
Mailing Address - Street 2:SUITE 360
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4643
Mailing Address - Country:US
Mailing Address - Phone:601-200-4370
Mailing Address - Fax:601-200-4375
Practice Address - Street 1:971 LAKELAND DR
Practice Address - Street 2:SUITE 360
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4643
Practice Address - Country:US
Practice Address - Phone:601-200-4370
Practice Address - Fax:601-200-4375
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2015-08-27
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MS11495208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110269Medicaid
MSB30270Medicare UPIN
MS399042YJ9XMedicare PIN