MEDICARE: DAVIS DERMATOLOGY, PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207NS0135X	Procedural Dermatology Physician	ME51662	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1104330224
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIS DERMATOLOGY, PA

Provider Business Mailing Address
First Line	:	504 S ORANGE ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7319
Country	:	US
Telephone Number	:	386-423-2218
Fax Number	:

Provider Business Practice Location Address
First Line	:	504 S ORANGE ST
Second Line	:
City	:	NEW SMYRNA BEACH
State	:	FL
Zip	:	32168-7319
Country	:	US
Telephone Number	:	386-423-2218
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. VALERIE DAVIS
Credential	:	MD
Telephone Number	:	386-423-2218

Provider Enumeration Date	:	11/28/2017
Last Update Date	:	06/16/2018

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