Provider Demographics
NPI:1255597142
Name:DAVIS, GEORGE BERTON II (MD)
Entity type:Individual
Prefix:
First Name:GEORGE
Middle Name:BERTON
Last Name:DAVIS
Suffix:II
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:49 SECOND STREET
Mailing Address - City:MALONE
Mailing Address - State:NY
Mailing Address - Zip Code:12953-0148
Mailing Address - Country:US
Mailing Address - Phone:518-483-2171
Mailing Address - Fax:
Practice Address - Street 1:133 PARK STREET
Practice Address - Street 2:
Practice Address - City:MALONE
Practice Address - State:NY
Practice Address - Zip Code:12953-0729
Practice Address - Country:US
Practice Address - Phone:518-483-3000
Practice Address - Fax:518-481-2818
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY085787207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354114Medicaid
NY00354114Medicaid