Provider Demographics
NPI:1417523705
Name:DAVIS, BRYANT
Entity Type:Individual
Prefix:
First Name:BRYANT
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1440 ALABAMA AVE SE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-5051
Mailing Address - Country:US
Mailing Address - Phone:240-596-9275
Mailing Address - Fax:
Practice Address - Street 1:134 RIVERWATCH DR # 134
Practice Address - Street 2:
Practice Address - City:INDIAN HEAD
Practice Address - State:MD
Practice Address - Zip Code:20640-1557
Practice Address - Country:US
Practice Address - Phone:301-535-7202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2023-12-12
Deactivation Date:2021-07-27
Deactivation Code:
Reactivation Date:2023-11-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant