Provider Demographics
NPI:1164094942
Name:DAVIS, EVAN (ATC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 ROSELEAH AVE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-2055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:156 ROSELEAH AVE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-2055
Practice Address - Country:US
Practice Address - Phone:860-614-2122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-12
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000721207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports MedicineGroup - Single Specialty