Provider Demographics
NPI:1639328743
Name:DAVIS, DANIELLE RENAE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIELLE
Middle Name:RENAE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1228 HARDEN ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-1800
Mailing Address - Country:US
Mailing Address - Phone:803-733-5969
Mailing Address - Fax:803-217-0026
Practice Address - Street 1:145 EXECUTIVE DR
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2952
Practice Address - Country:US
Practice Address - Phone:803-733-5969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-12
Last Update Date:2009-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.121545208000000X
SC31538208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics