Provider Demographics
NPI:1639150790
Name:WILLIAM J. DAVANZO, M.D., P.C.
Entity Type:Organization
Organization Name:WILLIAM J. DAVANZO, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:DAVANZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:912-634-7714
Mailing Address - Street 1:143 FOLLINS LN
Mailing Address - Street 2:
Mailing Address - City:SAINT 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:SAINT 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-07
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA050009174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000919234JMedicaid
GA000919234HMedicaid
GADB1236OtherRAILROAD MEDICARE
GA000919234IMedicaid
GA000919234IMedicaid
GAGRP6241Medicare PIN