Basic Information
| Provider Information | |||||||||
| NPI: | 1700848926 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | GWYNETH | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 10744 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337578744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7275320002 | ||||||||
| FaxNumber: | 7272664928 | ||||||||
| Practice Location | |||||||||
| Address1: | 1601 W TIMBERLANE DR | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | PLANT CITY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335660957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8137544611 | ||||||||
| FaxNumber: | 8134438169 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2006 | ||||||||
| LastUpdateDate: | 01/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | ME84651 | FL | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 265698100 | 05 | FL | MEDICAID |