Provider Demographics
NPI:1700804978
Name:DAVIS, MATTHEW SHANE (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SHANE
Last Name:DAVIS
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 1:7191 CAHABA VALLEY RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35242-6402
Mailing Address - Country:US
Mailing Address - Phone:205-533-6644
Mailing Address - Fax:888-258-4852
Practice Address - Street 1:7191 CAHABA VALLEY RD
Practice Address - Street 2:SUITE 205
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35242-6402
Practice Address - Country:US
Practice Address - Phone:205-533-6644
Practice Address - Fax:888-258-4852
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2014-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL0023917174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009938744Medicaid
AL009941508Medicaid
AL009938744Medicaid
AL009941508Medicaid