Healthcare Provider Details

I. General information

NPI: 1316163215
Provider Name (Legal Business Name): GEORGIA ANN DAVIS M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 BEDFORD DR SUITE 101
MELBOURNE FL
32940-1987
US

IV. Provider business mailing address

1112 RICKARD RD SUITE B
SPRINGFIELD IL
62704-1017
US

V. Phone/Fax

Practice location:
  • Phone: 321-622-8114
  • Fax: 321-622-4649
Mailing address:
  • Phone: 217-787-9540
  • Fax: 217-787-9183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number036-078693
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2084P0005X
TaxonomyNeurodevelopmental Disabilities Physician
License Number036-078693
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036-078693
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number036-078693
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: