=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821626052
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DERICK C DAVIS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/01/2020
-----------------------------------------------------
Last Update Date | 10/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5555 PEACHTREE DUNWOODY RD STE G65
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30342-1710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-843-3323
-----------------------------------------------------
Fax | 404-574-5944
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 152 COLOR CIR
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30317-2538
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-639-3308
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 103808
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------