Basic Information
| Provider Information | |||||||||
| NPI: | 1598084717 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645228614 | ||||||||
| FaxNumber: | 7069220604 | ||||||||
| Practice Location | |||||||||
| Address1: | 701 GROVE RD FL 5 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296054210 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644554411 | ||||||||
| FaxNumber: | 8644554480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2010 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 072564 | GA | N | Allopathic & Osteopathic Physicians | Pediatrics | 208000000X | 85095 | SC | N | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | 85095 | SC | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 072564 | GA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 003151477C | 05 | GA | MEDICAID | 003151477D | 05 | GA | MEDICAID |