Provider Demographics
NPI:1871588012
Name:DAVIS, BRENT O'BRYAN (MD)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:O'BRYAN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:619 S FLEISHEL AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-2004
Mailing Address - Country:US
Mailing Address - Phone:903-595-5514
Mailing Address - Fax:
Practice Address - Street 1:619 S FLEISHEL AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2004
Practice Address - Country:US
Practice Address - Phone:903-595-5514
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL8663207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX244841403OtherUNITED HEALTHCARE
TX8G7381OtherBCBS
TX166213201Medicaid
TX7571606OtherAETNA
TX8G7381OtherBCBS
TX166213201Medicaid
TXP00143637Medicare PIN