Basic Information
Provider Information | |||||||||
NPI: | 1194179523 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | FRANKLIN | ||||||||
MiddleName: | BRENT | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DAVIS | ||||||||
OtherFirstName: | FRANKY | ||||||||
OtherMiddleName: | BRENT | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: | JR. | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 4 LIVE OAK CT | ||||||||
Address2: |   | ||||||||
City: | MOULTRIE | ||||||||
State: | GA | ||||||||
PostalCode: | 317686783 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2297852400 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 4 LIVE OAK CT | ||||||||
Address2: |   | ||||||||
City: | MOULTRIE | ||||||||
State: | GA | ||||||||
PostalCode: | 317686783 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2297852400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2016 | ||||||||
LastUpdateDate: | 06/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207X00000X | 88301 | GA | Y |   | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.