=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932385960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P. CARL DAVIDSON MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2008
-----------------------------------------------------
Last Update Date | 01/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10366 COMMERCE ST
-----------------------------------------------------
City | SUMMERVILLE
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30747-1471
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-857-7777
-----------------------------------------------------
Fax | 706-857-7877
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1403 CINDERELLA RD
-----------------------------------------------------
City | LOOKOUT MTN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30750-2610
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-346-8629
-----------------------------------------------------
Fax | 706-346-8629
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | P CARL DAVIDSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 706-291-7360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | 29861
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------