Provider Demographics
NPI:1982042735
Name:DAVIS, LAURA (MD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name: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 1:17808 NE CHARLIE JOHNS ST
Mailing Address - Street 2:
Mailing Address - City:BLOUNTSTOWN
Mailing Address - State:FL
Mailing Address - Zip Code:32424-1052
Mailing Address - Country:US
Mailing Address - Phone:850-674-4524
Mailing Address - Fax:850-674-2300
Practice Address - Street 1:17808 NE CHARLIE JOHNS ST
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1052
Practice Address - Country:US
Practice Address - Phone:850-674-4524
Practice Address - Fax:850-674-2300
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2016-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35765390200000X
FLME127053207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program