Provider Demographics
NPI:1710124789
Name:DAVIS, BOBBY
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4937 SHADOWOOD PKWY SE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-2347
Mailing Address - Country:US
Mailing Address - Phone:770-627-3065
Mailing Address - Fax:678-401-6161
Practice Address - Street 1:4937 SHADOWOOD PKWY SE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30339-2347
Practice Address - Country:US
Practice Address - Phone:770-627-3065
Practice Address - Fax:678-401-6161
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-13
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA033-R-0107251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000889842AMedicaid