Provider Demographics
NPI:1578528154
Name:DAVIS, GORDON BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:BRUCE
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 1:740 COOL SPRINGS BLVD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37067-6448
Mailing Address - Country:US
Mailing Address - Phone:615-778-1840
Mailing Address - Fax:615-778-1841
Practice Address - Street 1:740 COOL SPRINGS BLVD
Practice Address - Street 2:SUITE 140
Practice Address - City:FRANKLIN
Practice Address - State:TN
Practice Address - Zip Code:37067-6448
Practice Address - Country:US
Practice Address - Phone:615-778-1840
Practice Address - Fax:615-778-1841
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2013-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD 40174208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440605Medicaid
A46320Medicare UPIN