Provider Demographics
NPI:1902987902
Name:DAVIS, DEMEKISA SIDAMO (DOM)
Entity Type:Individual
Prefix:DR
First Name:DEMEKISA
Middle Name:SIDAMO
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 GULFPORT BLVD.
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:FL
Mailing Address - Zip Code:33707
Mailing Address - Country:US
Mailing Address - Phone:727-642-6470
Mailing Address - Fax:727-866-8575
Practice Address - Street 1:5301 GULFPORT BLVD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:FL
Practice Address - Zip Code:33707
Practice Address - Country:US
Practice Address - Phone:727-642-6470
Practice Address - Fax:727-866-8575
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP1210171100000X
ID175F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath