Healthcare Provider Details

I. General information

NPI: 1912273814
Provider Name (Legal Business Name): DAVIS PODIATRY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2012
Last Update Date: 03/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 POINDEXTER ST
JACKSON MS
39203-3048
US

IV. Provider business mailing address

128 POINDEXTER ST
JACKSON MS
39203-3048
US

V. Phone/Fax

Practice location:
  • Phone: 601-355-0026
  • Fax: 601-355-0069
Mailing address:
  • Phone: 601-355-0026
  • Fax: 601-355-0069

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number80207
License Number StateMS

VIII. Authorized Official

Name: DR. STANITIA W35500263550021 DAVIS
Title or Position: OWNER
Credential: DPM
Phone: 601-355-0026