Provider Demographics
NPI:1043459811
Name:CHARLES DAVENPORT MD PA
Entity type:Organization
Organization Name:CHARLES DAVENPORT MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVENPORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:941-951-2100
Mailing Address - Street 1:1250 S TAMIAMI TRL
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-2221
Mailing Address - Country:US
Mailing Address - Phone:941-951-2100
Mailing Address - Fax:941-894-3123
Practice Address - Street 1:1250 S TAMIAMI TRL
Practice Address - Street 2:SUITE 103
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-2221
Practice Address - Country:US
Practice Address - Phone:941-951-2100
Practice Address - Fax:941-894-3123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-18
Last Update Date:2009-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME608012085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
14237VMedicare PIN
FLE66351Medicare UPIN