Healthcare Provider Details

I. General information

NPI: 1982817904
Provider Name (Legal Business Name): WESLEY LANE DAVIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 BLACKFORD ST
CHATTANOOGA TN
37403-1405
US

IV. Provider business mailing address

975 EAST THIRD STREET ATTN: PROVIDER ENROLLMENT
CHATTANOOGA TN
37403-2147
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-6180
  • Fax: 423-778-7033
Mailing address:
  • Phone: 423-778-6180
  • Fax: 423-778-7033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number56277
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number61230
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number061230
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code2080P0202X
TaxonomyPediatric Cardiology Physician
License Number56277
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: