Provider Demographics
NPI:1750905808
Name:DAVIS, JOHN HOWARD
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HOWARD
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 1:101 N UNION AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-7067
Mailing Address - Country:US
Mailing Address - Phone:405-777-8275
Mailing Address - Fax:
Practice Address - Street 1:540 W WALLACE ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-5722
Practice Address - Country:US
Practice Address - Phone:405-777-8275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-04
Last Update Date:2021-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1750905808172V00000X
175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No172V00000XOther Service ProvidersCommunity Health Worker