Healthcare Provider Details

I. General information

NPI: 1538899018
Provider Name (Legal Business Name): IAN DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2022
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9200 113TH ST
SEMINOLE FL
33772-2800
US

IV. Provider business mailing address

2125 RIVER CLIFF DR
ROSWELL GA
30076-3905
US

V. Phone/Fax

Practice location:
  • Phone: 727-893-5050
  • Fax:
Mailing address:
  • Phone: 770-712-4685
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberDRPM2477
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: