Healthcare Provider Details

I. General information

NPI: 1780932004
Provider Name (Legal Business Name): ULYSSES DAVILA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2012
Last Update Date: 04/28/2025
Certification Date: 04/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 E 13TH AVE
CORDELE GA
31015-4245
US

IV. Provider business mailing address

110 E 13TH AVE
CORDELE GA
31015-4245
US

V. Phone/Fax

Practice location:
  • Phone: 229-273-0359
  • Fax: 229-273-0360
Mailing address:
  • Phone: 229-273-0359
  • Fax: 229-273-0360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number103895
License Number StateGA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: