Provider Demographics
NPI:1053614305
Name:VIJAYSELWYN DAVIS DHAS MD
Entity type:Organization
Organization Name:VIJAYSELWYN DAVIS DHAS MD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIHAYSELWYN
Authorized Official - Middle Name:DAVIS
Authorized Official - Last Name:DHAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-824-9444
Mailing Address - Street 1:PO BOX 840262
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-0262
Mailing Address - Country:US
Mailing Address - Phone:904-824-9444
Mailing Address - Fax:
Practice Address - Street 1:301 HEALTH PARK BLVD
Practice Address - Street 2:STE 219
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5793
Practice Address - Country:US
Practice Address - Phone:904-824-9444
Practice Address - Fax:904-819-9594
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-08
Last Update Date:2012-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104834207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL002960100Medicaid
FLEI365AMedicare PIN