Provider Demographics
NPI:1386746378
Name:DAVIS, STACY C (MD)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:C
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 WINTER ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-4708
Mailing Address - Country:US
Mailing Address - Phone:706-364-3371
Mailing Address - Fax:706-364-3380
Practice Address - Street 1:1450 WINTER ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904-4708
Practice Address - Country:US
Practice Address - Phone:706-364-3371
Practice Address - Fax:706-364-3380
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-01
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA043030208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000742948EMedicaid