| National Provider Identifier [NPI]: | 1821179003 |
| Last Name Of The Provider | DAVIS |
| First Name Of The Provider | JERRY |
| Middle Initial Of The Provider | T |
| Credentials Of The Provider | DO |
| Gender Of The Provider | M |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 6302 A JACKSBORO HWY |
| Street Address 2 Of The Provider | |
| City Of The Provider | FORT WORTH |
| Zip Code Of The Provider | 761353602 |
| State Code Of The Provider | TX |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Family Practice |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 62 |
| Number Of Services | 1564.5 |
| Number Of Medicare Beneficiaries | 283 |
| Total Submitted Charge Amount | 51809.32 |
| Total Medicare Allowed Amount | 48201.66 |
| Total Medicare Payment Amount | 31619.09 |
| Total Medicare Standardized Payment Amount | 34699.76 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 17 |
| Number Of Drug Services | 548.5 |
| Number Of Medicare Beneficiaries With Drug Services | 180 |
| Total Drug Submitted ChargeAmount | 1647.31 |
| Total Drug Medicare AllowedAmount | 1259.97 |
| Total Drug Medicare PaymentAmount | 1002.96 |
| Total Drug Medicare Standardized Payment Amount | 1002.96 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 45 |
| Number Of Medical Services | 1016 |
| Number Of Medicare Beneficiaries With Medical Services | 281 |
| Total Medical Submitted Charge Amount | 50162.01 |
| Total Medical Medicare Allowed Amount | 46941.69 |
| Total Medical Medicare Payment Amount | 30616.13 |
| Total Medical Medicare Standardized Payment Amount | 33696.8 |
| Average Age Of Beneficiaries | 72 |
| Number Of Beneficiaries Age Less65 | 33 |
| Number Of Beneficiaries Age 65 to 74 | 148 |
| Number Of Beneficiaries Age 75 to 84 | 67 |
| Number Of Beneficiaries Age Greater 84 | 35 |
| Number Of Female Beneficiaries | 165 |
| Number Of Male Beneficiaries | 118 |
| Number Of Non Hispanic White Beneficiaries | 238 |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | 33 |
| Number Of American Indian Alaska Native Beneficiaries | 0 |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | 263 |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | 20 |
| Percent Of With Atrial Fibrillation | 7 |
| Percent Of With Alzheimers Disease or Dementia | 10 |
| Percent Of With Asthma | 7 |
| Percent Of With Cancer | 6 |
| Percent Of With Heart Failure | 14 |
| Percent Of With Chronic Kidney Disease | 15 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 12 |
| Percent Of With Depression | 19 |
| Percent Of With Diabetes | 27 |
| Percent Of With Hyperlipidemia | 37 |
| Percent Of With Hypertension | 52 |
| Percent Of With Ischemic Heart Disease | 25 |
| Percent Of With Osteoporosis | 5 |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | 30 |
| Percent Of With Schizophrenia Other PsychoticDisorders | |
| Percent Of With Stroke | 4 |
| Average HCC Risk Score Of Beneficiaries | 1.0237 |