Provider Demographics
NPI:1508852476
Name:DAVIS, PHILLIP G (MD)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:G
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 1:7560 WINKLER RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33908-4159
Mailing Address - Country:US
Mailing Address - Phone:239-454-6868
Mailing Address - Fax:239-466-5254
Practice Address - Street 1:7560 WINKLER RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4159
Practice Address - Country:US
Practice Address - Phone:239-454-6868
Practice Address - Fax:239-466-5254
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51086207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD61084Medicare UPIN
FL04433AMedicare ID - Type Unspecified