Basic Information
Provider Information | |||||||||
NPI: | 1649499583 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | MELISSA | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 221 TECHNOLOGY PKWY NW | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301651369 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7622351000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 85 JOHN MADDOX DRIVE CONNECTOR NW | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301651233 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7622353730 | ||||||||
FaxNumber: | 7062349026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/25/2007 | ||||||||
LastUpdateDate: | 07/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 059141 | GA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 995946279A | 05 | GA |   | MEDICAID |