Provider Demographics
NPI:1063610293
Name:DAVIS, WAYNE ALBERT (DO)
Entity type:Individual
Prefix:
First Name:WAYNE
Middle Name:ALBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7500 N DREAMY DRAW DR STE 145
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-4668
Mailing Address - Country:US
Mailing Address - Phone:480-882-4545
Mailing Address - Fax:
Practice Address - Street 1:4131 N 24TH ST STE B102
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-6231
Practice Address - Country:US
Practice Address - Phone:480-882-4545
Practice Address - Fax:602-903-7091
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2025-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4825207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ484673Medicaid
AZZ186782Medicare PIN