Provider Demographics
NPI:1013042068
Name:DAVIS, DEVIN J (OD)
Entity Type:Individual
Prefix:
First Name:DEVIN
Middle Name:J
Last Name:DAVIS
Suffix:
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 1:139 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:CHADRON
Mailing Address - State:NE
Mailing Address - Zip Code:69337-2313
Mailing Address - Country:US
Mailing Address - Phone:308-432-2200
Mailing Address - Fax:308-432-3616
Practice Address - Street 1:139 W 3RD ST
Practice Address - Street 2:
Practice Address - City:CHADRON
Practice Address - State:NE
Practice Address - Zip Code:69337-2313
Practice Address - Country:US
Practice Address - Phone:308-432-2200
Practice Address - Fax:308-432-3616
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY200T152W00000X
NE1352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026126000Medicaid
WY114581900Medicaid
NENA2007001Medicare PIN
WY9425Medicare PIN
NEDS5329Medicare UPIN
WY114581900Medicaid
WYU40778Medicare UPIN
NE10026126000Medicaid