Healthcare Provider Details

I. General information

NPI: 1710253117
Provider Name (Legal Business Name): MATTHEW JONATHON DAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 09/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57 GERMANTOWN CT STE 204
CORDOVA TN
38018
US

IV. Provider business mailing address

P O BOX 1000 DEPT 457
MEMPHIS TN
38148-0001
US

V. Phone/Fax

Practice location:
  • Phone: 901-758-7888
  • Fax: 901-266-6445
Mailing address:
  • Phone: 901-275-3662
  • Fax: 901-271-0155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20860000X
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number57973
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: