Provider Demographics
NPI:1174926315
Name:A.C. DAVIS M.D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:A.C. DAVIS M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNA
Authorized Official - Middle Name:CHRISTINE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:985-951-7882
Mailing Address - Street 1:PO BOX 386
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70470-0386
Mailing Address - Country:US
Mailing Address - Phone:985-951-7882
Mailing Address - Fax:985-327-7873
Practice Address - Street 1:69164 HIGHWAY 59
Practice Address - Street 2:SUITE 1
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-7782
Practice Address - Country:US
Practice Address - Phone:985-951-7882
Practice Address - Fax:985-327-7873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA013663207RA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1185116Medicaid
LA1185116Medicaid