Provider Demographics
NPI:1710253117
Name:DAVIS, MATTHEW JONATHON (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JONATHON
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:P O BOX 1000 DEPT 457
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38148-0001
Mailing Address - Country:US
Mailing Address - Phone:901-275-3662
Mailing Address - Fax:901-271-0155
Practice Address - Street 1:57 GERMANTOWN CT STE 204
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018
Practice Address - Country:US
Practice Address - Phone:901-758-7888
Practice Address - Fax:901-266-6445
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH20860000X208600000X
TN57973208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery