Provider Demographics
NPI:1790784569
Name:HERON-DAVIS, RUTHANN ALETHIA (MD)
Entity Type:Individual
Prefix:DR
First Name:RUTHANN
Middle Name:ALETHIA
Last Name:HERON-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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-973-2106
Mailing Address - Fax:704-973-2395
Practice Address - Street 1:150 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1218
Practice Address - Country:US
Practice Address - Phone:704-973-2106
Practice Address - Fax:704-973-2395
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401226207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790182RMedicaid
NC89138H5Medicaid
NC89138H5Medicaid
NC2035936Medicare PIN
NC790182RMedicaid