Basic Information
| Provider Information | |||||||||
| NPI: | 1346621836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIES | ||||||||
| FirstName: | ANDRE | ||||||||
| MiddleName: | NICHOLAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 26067 | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841260067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396240400 | ||||||||
| FaxNumber: | 2396240401 | ||||||||
| Practice Location | |||||||||
| Address1: | 40 S HEATHWOOD DR STE A | ||||||||
| Address2: | |||||||||
| City: | MARCO ISLAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 341455026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2396248180 | ||||||||
| FaxNumber: | 2396248181 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2015 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME146100 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CQG44 | 01 | FL | BCBS | OTHER | 107466900 | 05 | FL | MEDICAID |