Healthcare Provider Details

I. General information

NPI: 1295701704
Provider Name (Legal Business Name): P. CARL DAVIDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 12/18/2024
Certification Date: 12/18/2024
Deactivation Date: 09/17/2008
Reactivation Date: 09/30/2008

III. Provider practice location address

10366 COMMERCE ST
SUMMERVILLE GA
30747-1471
US

IV. Provider business mailing address

1403 CINDERELLA RD
LOOKOUT MOUNTAIN GA
30750-2610
US

V. Phone/Fax

Practice location:
  • Phone: 706-857-7777
  • Fax:
Mailing address:
  • Phone: 706-936-8300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number029861
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: