Provider Demographics
NPI:1295393932
Name:DAVIS, ETHAN A (DPT)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3138 BUCK HILL PL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32817-5864
Mailing Address - Country:US
Mailing Address - Phone:407-575-9964
Mailing Address - Fax:
Practice Address - Street 1:3451 TECHNOLOGICAL AVE STE 1
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32817-8353
Practice Address - Country:US
Practice Address - Phone:407-681-2520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-29
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic