Provider Demographics
NPI:1457432601
Name:DAVOODI, PUYA (MD)
Entity Type:Individual
Prefix:DR
First Name:PUYA
Middle Name:
Last Name:DAVOODI
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 1:1296 SIMS ST STE B
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3873
Mailing Address - Country:US
Mailing Address - Phone:770-534-1856
Mailing Address - Fax:
Practice Address - Street 1:1296 SIMS ST STE B
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3835
Practice Address - Country:US
Practice Address - Phone:770-534-1856
Practice Address - Fax:770-531-0355
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL25628208600000X
FLTRN136692086S0122X
FLME1119562086S0122X
GA0628332086S0122X, 208D00000X, 208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL006099600Medicaid
FLGH441ZMedicare PIN