Provider Demographics
NPI:1609976265
Name:DAVIS, JIMMY W (MD)
Entity Type:Individual
Prefix:
First Name:JIMMY
Middle Name:W
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 1:101 STEPHEN J WHITE BLVD
Mailing Address - Street 2:
Mailing Address - City:TALLADEGA
Mailing Address - State:AL
Mailing Address - Zip Code:35160-2106
Mailing Address - Country:US
Mailing Address - Phone:256-315-2252
Mailing Address - Fax:256-362-5959
Practice Address - Street 1:101 STEPHEN J WHITE BLVD
Practice Address - Street 2:
Practice Address - City:TALLADEGA
Practice Address - State:AL
Practice Address - Zip Code:35160-2106
Practice Address - Country:US
Practice Address - Phone:256-315-2252
Practice Address - Fax:256-362-5959
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6666207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL142299Medicaid
AL000038905Medicaid
AL142543Medicaid
C73243Medicare UPIN
AL000038905Medicaid
AL102I110062Medicare PIN