Provider Demographics
NPI:1487656658
Name:DAVIES, THEODORE EDWIN CLYDE (MD)
Entity type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:EDWIN CLYDE
Last Name:DAVIES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2603 KENTUCKY AVE
Mailing Address - Street 2:STE 404
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3814
Mailing Address - Country:US
Mailing Address - Phone:270-443-6472
Mailing Address - Fax:270-442-1649
Practice Address - Street 1:2603 KENTUCKY AVE
Practice Address - Street 2:STE 404
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3814
Practice Address - Country:US
Practice Address - Phone:270-443-6472
Practice Address - Fax:270-442-1649
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY16229207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00391203OtherRAILROAD MEDICARE
KY64162290Medicaid
KYP00391203OtherRAILROAD MEDICARE
KY64162290Medicaid