MEDICARE: DAVIS PODIATRY, LLC

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	213ES0103X	Foot & Ankle Surgery Podiatrist	80207	MS

General Provider Information

NPI Number	:	1912273814
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DAVIS PODIATRY, LLC

Provider Business Mailing Address
First Line	:	128 POINDEXTER ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39203-3048
Country	:	US
Telephone Number	:	601-355-0026
Fax Number	:	601-355-0069

Provider Business Practice Location Address
First Line	:	128 POINDEXTER ST
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39203-3048
Country	:	US
Telephone Number	:	601-355-0026
Fax Number	:	601-355-0069

Authorized Official
Title or Position	:	OWNER
Name	:	DR. STANITIA W35500263550021 DAVIS
Credential	:	DPM
Telephone Number	:	601-355-0026

Provider Enumeration Date	:	03/26/2012
Last Update Date	:	03/26/2012

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