Provider Demographics
NPI:1801121108
Name:DAVIS, CARLY RAE (MD)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:RAE
Last Name:DAVIS
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12391 S 4000 W
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:UT
Mailing Address - Zip Code:84096-7012
Mailing Address - Country:US
Mailing Address - Phone:801-302-1700
Mailing Address - Fax:
Practice Address - Street 1:12391 S 4000 W
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:UT
Practice Address - Zip Code:84096-7012
Practice Address - Country:US
Practice Address - Phone:801-302-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-05
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR70650208000000X
UT7996415-12052080P0208X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases