Provider Demographics
NPI:1396125076
Name:DAVIS, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 DIXIE ST STE 220
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-3889
Mailing Address - Country:US
Mailing Address - Phone:770-838-8710
Mailing Address - Fax:770-812-5735
Practice Address - Street 1:690 DALLAS HWY STE 301
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-1262
Practice Address - Country:US
Practice Address - Phone:770-459-3850
Practice Address - Fax:770-456-3620
Is Sole Proprietor?:No
Enumeration Date:2015-06-08
Last Update Date:2021-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA82162207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program