Provider Demographics
NPI:1700848926
Name:DAVIS, GWYNETH A (MD)
Entity Type:Individual
Prefix:DR
First Name:GWYNETH
Middle Name:A
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:PO BOX 10744
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33757-8744
Mailing Address - Country:US
Mailing Address - Phone:727-532-0002
Mailing Address - Fax:727-266-4928
Practice Address - Street 1:1601 W TIMBERLANE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:PLANT CITY
Practice Address - State:FL
Practice Address - Zip Code:33566-0957
Practice Address - Country:US
Practice Address - Phone:813-754-4611
Practice Address - Fax:813-443-8169
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME84651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL265698100Medicaid
FL265698100Medicaid
FL4604090001Medicare NSC
FL4604090001Medicare NSC