Healthcare Provider Details

I. General information

NPI: 1457432601
Provider Name (Legal Business Name): PUYA DAVOODI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1296 SIMS ST STE B
GAINESVILLE GA
30501-3835
US

IV. Provider business mailing address

1296 SIMS ST STE B
GAINESVILLE GA
30501-3873
US

V. Phone/Fax

Practice location:
  • Phone: 770-534-1856
  • Fax: 770-531-0355
Mailing address:
  • Phone: 770-534-1856
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL25628
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberTRN13669
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License NumberME111956
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number062833
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number062833
License Number StateGA
# 6
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number062833
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: