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General NPI Number Information
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NPI Number | 1497445449
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Entity Type | Individual
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Provider Name | JOHNATHON DEWAYNE DAVIS DO
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Gender | Male
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Dates
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Enumeration Date | 05/12/2023
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Last Update Date | 05/12/2023
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Provider Practice Location Address
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Address Line | 1001 HEALTH PARK DR
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City | BRENTWOOD
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State | TN
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Zip | 37027-5721
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Country | US
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Telephone | 615-762-0529
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Fax |
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Provider Business Mailing Address
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Address Line | 600 HERITAGE DR APT 288
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City | MADISON
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State | TN
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Zip | 37115-6025
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Country | US
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Telephone | 615-762-0529
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171W00000X
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Taxonomy Name | Contractor
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License Number | 14005
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License Number State | TN
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