Provider Demographics
NPI:1225105489
Name:DAVIS, MATTHEW EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:EDWIN
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 1:33 UPPER RIVERDALE RD SW
Mailing Address - Street 2:SUITE 117
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-2626
Mailing Address - Country:US
Mailing Address - Phone:770-991-1170
Mailing Address - Fax:770-991-0107
Practice Address - Street 1:33 UPPER RIVERDALE RD SW
Practice Address - Street 2:SUITE 117
Practice Address - City:RIVERDALE
Practice Address - State:GA
Practice Address - Zip Code:30274-2626
Practice Address - Country:US
Practice Address - Phone:770-991-1170
Practice Address - Fax:770-991-0107
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA016052207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00065403BMedicaid
GA00065403BMedicaid