Healthcare Provider Details

I. General information

NPI: 1639150790
Provider Name (Legal Business Name): WILLIAM J. DAVANZO, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 05/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

143 FOLLINS LN
SAINT SIMONS ISLAND GA
31522-4263
US

IV. Provider business mailing address

143 FOLLINS LN
SAINT SIMONS ISLAND GA
31522-4263
US

V. Phone/Fax

Practice location:
  • Phone: 912-634-7714
  • Fax: 912-634-7734
Mailing address:
  • Phone: 912-634-7714
  • Fax: 912-634-7734

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number050009
License Number StateGA

VIII. Authorized Official

Name: DR. WILLIAM JAMES DAVANZO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 912-634-7714