Provider Demographics
NPI:1437151172
Name:DAVIS, EDWARD LEBRETTA (DO)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEBRETTA
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6100 WINKLER RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-8126
Mailing Address - Country:US
Mailing Address - Phone:239-433-3500
Mailing Address - Fax:239-433-0435
Practice Address - Street 1:6100 WINKLER RD
Practice Address - Street 2:SUITE C
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-8126
Practice Address - Country:US
Practice Address - Phone:239-433-3500
Practice Address - Fax:239-433-0435
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-12
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS00040962084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL066798600Medicaid
FLF14776Medicare UPIN
FL82310Medicare ID - Type Unspecified