Provider Demographics
NPI:1578504791
Name:DAVIS, GLENDA H (MD)
Entity Type:Individual
Prefix:DR
First Name:GLENDA
Middle Name:H
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:ROUTE 2
Mailing Address - Street 2:BOX 4918
Mailing Address - City:HAWKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31036
Mailing Address - Country:US
Mailing Address - Phone:478-783-2625
Mailing Address - Fax:727-507-3618
Practice Address - Street 1:1120 MORNINGSIDE DR
Practice Address - Street 2:
Practice Address - City:PERRY
Practice Address - State:GA
Practice Address - Zip Code:31069-2906
Practice Address - Country:US
Practice Address - Phone:478-988-1706
Practice Address - Fax:478-988-1794
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA025741207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
D39701Medicare UPIN