Provider Demographics
NPI:1598909178
Name:DAVIS, CAROLYN (MD)
Entity Type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CAROLYN
Other - Middle Name:
Other - Last Name:CHURCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:913 MAR WALT DR
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6647
Mailing Address - Country:US
Mailing Address - Phone:850-243-8229
Mailing Address - Fax:850-863-2540
Practice Address - Street 1:36468 EMERALD COAST PKWY
Practice Address - Street 2:SUITE 8102, OLD SOUTH CENTRE
Practice Address - City:DESTIN
Practice Address - State:FL
Practice Address - Zip Code:32541-4799
Practice Address - Country:US
Practice Address - Phone:850-650-9500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-27
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 96897208D00000X
GA050010208D00000X
ALMD 27497208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice