MEDICARE: DR. CAROLYN DAVIS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	ME 96897	FL
2	208D00000X	General Practice Physician	050010	GA
3	208D00000X	General Practice Physician	MD 27497	AL

General Provider Information

NPI Number	:	1598909178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CAROLYN DAVIS M.D.

Provider Business Mailing Address
First Line	:	913 MAR WALT DR
Second Line	:
City	:	FORT WALTON BEACH
State	:	FL
Zip	:	32547-6647
Country	:	US
Telephone Number	:	850-243-8229
Fax Number	:	850-863-2540

Provider Business Practice Location Address
First Line	:	36468 EMERALD COAST PKWY
Second Line	:	SUITE 8102, OLD SOUTH CENTRE
City	:	DESTIN
State	:	FL
Zip	:	32541-4799
Country	:	US
Telephone Number	:	850-650-9500
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/27/2009
Last Update Date	:	04/27/2009

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