Provider Demographics
NPI:1356919914
Name:DAVIS, AVI IONTEL
Entity type:Individual
Prefix:
First Name:AVI
Middle Name:IONTEL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19195 MYSTIC POINTE DR APT 1903
Mailing Address - Street 2:
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-4508
Mailing Address - Country:US
Mailing Address - Phone:786-553-3251
Mailing Address - Fax:
Practice Address - Street 1:BRANDYWINE HOSPITAL 201 REECEVILLE RD
Practice Address - Street 2:
Practice Address - City:COATESVILLE
Practice Address - State:PA
Practice Address - Zip Code:19320
Practice Address - Country:US
Practice Address - Phone:610-383-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-11
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT223217390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program