Healthcare Provider Details

I. General information

NPI: 1467449041
Provider Name (Legal Business Name): TYRONE TEAKO DAVIS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 MADISON AVE
MEMPHIS TN
38104-2226
US

IV. Provider business mailing address

1204 MADISON AVE 2
MEMPHIS TN
38104-2226
US

V. Phone/Fax

Practice location:
  • Phone: 901-523-7698
  • Fax: 901-272-2045
Mailing address:
  • Phone: 901-523-7698
  • Fax: 901-272-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number652
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: