Provider Demographics
NPI:1649499583
Name:DAVIS, MELISSA DAWN (MD)
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:DAWN
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 1:221 TECHNOLOGY PKWY NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1369
Mailing Address - Country:US
Mailing Address - Phone:762-235-1000
Mailing Address - Fax:
Practice Address - Street 1:85 JOHN MADDOX DRIVE CONNECTOR NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1233
Practice Address - Country:US
Practice Address - Phone:762-235-3730
Practice Address - Fax:706-234-9026
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059141208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA995946279AMedicaid
GA202I375332Medicare PIN