Provider Demographics
NPI:1881177731
Name:ISON, DAVIS
Entity type:Individual
Prefix:
First Name:DAVIS
Middle Name:
Last Name:ISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5980 SEVILLE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE PARK
Mailing Address - State:GA
Mailing Address - Zip Code:31636-4934
Mailing Address - Country:US
Mailing Address - Phone:229-251-4222
Mailing Address - Fax:
Practice Address - Street 1:5980 SEVILLE DR
Practice Address - Street 2:
Practice Address - City:LAKE PARK
Practice Address - State:GA
Practice Address - Zip Code:31636-4934
Practice Address - Country:US
Practice Address - Phone:229-251-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA$$$$$$$$$Medicaid