Healthcare Provider Details

I. General information

NPI: 1235120684
Provider Name (Legal Business Name): SHELTON AVERY DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 08/29/2023
Certification Date: 08/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8901 ROCKVILLE PIKE DEPT OF
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

8901 ROCKVILLE PIKE DEPT OF
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-7753
  • Fax: 301-295-8358
Mailing address:
  • Phone: 301-295-7753
  • Fax: 301-295-8358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number0101057082
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberD0066221
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: