Healthcare Provider Details

I. General information

NPI: 1679534945
Provider Name (Legal Business Name): GRACE VIOLET DAVIS M.D., M.P.H.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 07/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 W KELLY ST
SYLVESTER GA
31791-2021
US

IV. Provider business mailing address

203 W KELLY ST P.O. BOX 5367
SYLVESTER GA
31791-2021
US

V. Phone/Fax

Practice location:
  • Phone: 229-777-0488
  • Fax: 229-777-0476
Mailing address:
  • Phone: 229-777-0488
  • Fax: 229-777-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number039770
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: