Provider Demographics
NPI:1669409298
Name:DAVIS-BOUTTE, WINDELL C (MD)
Entity type:Individual
Prefix:DR
First Name:WINDELL
Middle Name:C
Last Name:DAVIS-BOUTTE
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 1:2165 SPENCERS WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-1246
Mailing Address - Country:US
Mailing Address - Phone:770-938-4001
Mailing Address - Fax:770-938-4849
Practice Address - Street 1:4650 STONE MOUNTAIN GA
Practice Address - Street 2:
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:770-938-4001
Practice Address - Fax:770-938-4849
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA039318207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAG54474Medicare UPIN
GA07BBSHJMedicare ID - Type Unspecified