Provider Demographics
NPI:1003102633
Name:DAUGHTRY, DAVID R JR (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:R
Last Name:DAUGHTRY
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 E CENTER ST
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27292-4112
Mailing Address - Country:US
Mailing Address - Phone:336-249-8901
Mailing Address - Fax:336-248-2695
Practice Address - Street 1:801 E CENTER ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:NC
Practice Address - Zip Code:27292-4401
Practice Address - Country:US
Practice Address - Phone:336-249-8901
Practice Address - Fax:336-248-2695
Is Sole Proprietor?:No
Enumeration Date:2011-06-22
Last Update Date:2018-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2220152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5918628Medicaid