Provider Demographics
NPI:1043430481
Name:DAVIS, MARTHA L (DPO)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 S WASHINGTON ST
Mailing Address - Street 2:LINDA'S EYEWEAR
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37804-5800
Mailing Address - Country:US
Mailing Address - Phone:865-977-0285
Mailing Address - Fax:865-977-1459
Practice Address - Street 1:312 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5800
Practice Address - Country:US
Practice Address - Phone:865-977-0285
Practice Address - Fax:865-977-1459
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-26
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN719156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician