Provider Demographics
NPI:1215161153
Name:DAVIS, GAVIN WADE (MD)
Entity type:Individual
Prefix:DR
First Name:GAVIN
Middle Name:WADE
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 1:4723 SUNSET BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-9151
Mailing Address - Country:US
Mailing Address - Phone:803-999-3937
Mailing Address - Fax:
Practice Address - Street 1:4723 SUNSET BLVD STE A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-9151
Practice Address - Country:US
Practice Address - Phone:803-999-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2020-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA72543207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1215161153OtherNPI
GA1215161153OtherNPI