Healthcare Provider Details

I. General information

NPI: 1396125076
Provider Name (Legal Business Name): RYAN DAVIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2015
Last Update Date: 06/18/2021
Certification Date: 06/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

690 DALLAS HWY STE 301
VILLA RICA GA
30180-1262
US

IV. Provider business mailing address

706 DIXIE ST STE 220
CARROLLTON GA
30117-3889
US

V. Phone/Fax

Practice location:
  • Phone: 770-459-3850
  • Fax: 770-456-3620
Mailing address:
  • Phone: 770-838-8710
  • Fax: 770-812-5735

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number82162
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: