Provider Demographics
NPI:1598947970
Name:DAVANZO, WILLIAM JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:JAMES
Last Name:DAVANZO
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 1:143 FOLLINS LN
Mailing Address - Street 2:
Mailing Address - City:ST SIMONS ISLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31522-4263
Mailing Address - Country:US
Mailing Address - Phone:912-634-7714
Mailing Address - Fax:912-634-7734
Practice Address - Street 1:143 FOLLINS LN
Practice Address - Street 2:
Practice Address - City:ST SIMONS ISLAND
Practice Address - State:GA
Practice Address - Zip Code:31522-4263
Practice Address - Country:US
Practice Address - Phone:912-634-7714
Practice Address - Fax:912-634-7734
Is Sole Proprietor?:No
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA50009207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00091923HMedicaid
GRP6241Medicare PIN
GA00091923HMedicaid
GA11BDXHHMedicare PIN