Provider Demographics
NPI:1942204805
Name:DAVIS, WILLIAM GLENN (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:GLENN
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 1:15 IRIS LN
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-7528
Mailing Address - Country:US
Mailing Address - Phone:931-456-2728
Mailing Address - Fax:931-456-5446
Practice Address - Street 1:220 N CHANCERY ST
Practice Address - Street 2:
Practice Address - City:MC MINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2551
Practice Address - Country:US
Practice Address - Phone:931-473-2487
Practice Address - Fax:931-473-8782
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2023-06-02
Deactivation Date:2006-03-21
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TNMD009365207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3943261Medicaid
TN3943261Medicaid
TN4659120001Medicare NSC
TN3178258Medicaid