Provider Demographics
NPI:1770502098
Name:DAVIS, LARRY J (MD)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:J
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:PO BOX 402643
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-2643
Mailing Address - Country:US
Mailing Address - Phone:727-893-6182
Mailing Address - Fax:
Practice Address - Street 1:701 6TH ST S
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701-4814
Practice Address - Country:US
Practice Address - Phone:727-893-6182
Practice Address - Fax:727-893-6861
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-18
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0024195207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067949600Medicaid
FL78192ZMedicare ID - Type Unspecified
FL067949600Medicaid