Provider Demographics
NPI:1225846645
Name:DAVIS, KORY
Entity type:Individual
Prefix:
First Name:KORY
Middle Name:
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:PO BOX 189
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-0189
Mailing Address - Country:US
Mailing Address - Phone:580-319-7305
Mailing Address - Fax:580-319-7305
Practice Address - Street 1:698 WESTSIDE DR STE 102
Practice Address - Street 2:
Practice Address - City:DURANT
Practice Address - State:OK
Practice Address - Zip Code:74701-3085
Practice Address - Country:US
Practice Address - Phone:580-924-7331
Practice Address - Fax:580-924-7332
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist