Basic Information
| Provider Information | |||||||||
| NPI: | 1356368963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVENPORT | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | P. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | 5153 N 9TH AVE | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048785 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8505054700 | ||||||||
| FaxNumber: | 8504734515 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 09/13/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0202X | ME69456 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Cardiology |
ID Information
| ID | Type | State | Issuer | Description | 009711160 | 05 | AL | MEDICAID | 00123090 | 05 | MS | MEDICAID | 379494600 | 05 | FL | MEDICAID |