Basic Information
| Provider Information | |||||||||
| NPI: | 1396125076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | RYAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 706 DIXIE ST STE 220 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173889 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388710 | ||||||||
| FaxNumber: | 7708125735 | ||||||||
| Practice Location | |||||||||
| Address1: | 690 DALLAS HWY STE 301 | ||||||||
| Address2: | |||||||||
| City: | VILLA RICA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301801262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704593850 | ||||||||
| FaxNumber: | 7704563620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2015 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 82162 | GA | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.