Provider Demographics
NPI:1376791244
Name:DAVIS, LEO (MD)
Entity Type:Individual
Prefix:
First Name:LEO
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:70 MOUNTAIN DR STE C
Mailing Address - Street 2:
Mailing Address - City:DAHLONEGA
Mailing Address - State:GA
Mailing Address - Zip Code:30533-1629
Mailing Address - Country:US
Mailing Address - Phone:706-867-0145
Mailing Address - Fax:706-867-0148
Practice Address - Street 1:70 MOUNTAIN DR STE C
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-1629
Practice Address - Country:US
Practice Address - Phone:706-867-0145
Practice Address - Fax:706-867-0148
Is Sole Proprietor?:No
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA012310207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND39709Medicare UPIN