Provider Demographics
NPI:1194711283
Name:DAVIS, KEVIN WESLEY (MD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:WESLEY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:775 POPLAR RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30265-8300
Mailing Address - Country:US
Mailing Address - Phone:770-400-4610
Mailing Address - Fax:678-423-2739
Practice Address - Street 1:775 POPLAR RD
Practice Address - Street 2:SUITE 250
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-8300
Practice Address - Country:US
Practice Address - Phone:770-400-4610
Practice Address - Fax:678-423-2739
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA064355208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA764840117AMedicaid