Provider Demographics
NPI:1609075902
Name:DAVIS, EDDIE (DPM)
Entity Type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 GALLERY CIR STE 119
Mailing Address - Street 2:SUITE 119
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3328
Mailing Address - Country:US
Mailing Address - Phone:210-490-3668
Mailing Address - Fax:
Practice Address - Street 1:109 GALLERY CIR STE 119
Practice Address - Street 2:SUITE 119
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3328
Practice Address - Country:US
Practice Address - Phone:210-490-3668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2021-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1818213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1913154Medicaid
TX1913154 INDIVIDUALMedicaid
TX8F9813Medicare PIN