Provider Demographics
NPI:1346384773
Name:DAVIS, JONATHAN MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:MICHAEL
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 1:240 N HIGHLAND AVE NE
Mailing Address - Street 2:UNIT 3312
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30307-5609
Mailing Address - Country:US
Mailing Address - Phone:706-513-0201
Mailing Address - Fax:
Practice Address - Street 1:240 N HIGHLAND AVE NE
Practice Address - Street 2:UNIT 3312
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30307-5609
Practice Address - Country:US
Practice Address - Phone:706-513-0201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2011-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA59630207Q00000X
NC2007-00142207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA051230593DMedicaid
GA511I080432Medicare PIN