Healthcare Provider Details

I. General information

NPI: 1104874197
Provider Name (Legal Business Name): BRENT WILLIAM DAVIDSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 01/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 S MAIN ST
HIAWASSEE GA
30546-3408
US

IV. Provider business mailing address

PO BOX 509
HIAWASSEE GA
30546-0509
US

V. Phone/Fax

Practice location:
  • Phone: 706-896-2222
  • Fax: 706-896-7872
Mailing address:
  • Phone: 706-896-2222
  • Fax: 706-896-7872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number029622
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: