Basic Information
Provider Information
NPI: 1003806464
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: DAVANG
FirstName: JEFFREY
MiddleName: FRED
NamePrefix: MR.
NameSuffix:  
Credential: CRNA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 3719 COUNTY ROAD 131
Address2:  
City: WHARTON
State: TX
PostalCode: 774888535
CountryCode: US
TelephoneNumber: 7132525200
FaxNumber: 9795631693
Practice Location
Address1: 1501 E MOCKINGBIRD LN
Address2: 101
City: VICTORIA
State: TX
PostalCode: 779042155
CountryCode: US
TelephoneNumber: 3615732481
FaxNumber: 3615762434
Other Information
ProviderEnumerationDate: 10/26/2005
LastUpdateDate: 08/05/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207L00000X642422TXN Allopathic & Osteopathic PhysiciansAnesthesiology 
367500000X642422TXY Physician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered 

ID Information
IDTypeStateIssuerDescription
83842U01TXBLUE CROSS/BLUE SHIELDOTHER
15104480205TX MEDICAID
P0009029301TXRAILROAD MEDICAREOTHER
05298301TXRECERTIFICATIONOTHER


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