Provider Demographics
NPI:1689617813
Name:DAVIS, GLEN F (MD)
Entity Type:Individual
Prefix:
First Name:GLEN
Middle Name:F
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 1:4106 W LAKE MARY BLVD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LAKE MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32746-3315
Mailing Address - Country:US
Mailing Address - Phone:407-333-2503
Mailing Address - Fax:
Practice Address - Street 1:4106 W LAKE MARY BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3315
Practice Address - Country:US
Practice Address - Phone:407-333-2503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME37813207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
59294ZMedicare ID - Type Unspecified
98593Medicare ID - Type Unspecified
D57062Medicare UPIN