Provider Demographics
NPI:1912273814
Name:DAVIS PODIATRY, LLC
Entity Type:Organization
Organization Name:DAVIS PODIATRY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STANITIA
Authorized Official - Middle Name:W35500263550021
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-355-0026
Mailing Address - Street 1:128 POINDEXTER ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39203-3048
Mailing Address - Country:US
Mailing Address - Phone:601-355-0026
Mailing Address - Fax:601-355-0069
Practice Address - Street 1:128 POINDEXTER ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39203-3048
Practice Address - Country:US
Practice Address - Phone:601-355-0026
Practice Address - Fax:601-355-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80207213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty