Provider Demographics
NPI:1083154264
Name:DR JAMES E DAVIS JR
Entity Type:Organization
Organization Name:DR JAMES E DAVIS JR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:217-877-0312
Mailing Address - Street 1:3411 N WOODFORD ST
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-2861
Mailing Address - Country:US
Mailing Address - Phone:217-877-0312
Mailing Address - Fax:217-877-0397
Practice Address - Street 1:3411 N WOODFORD ST
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-2861
Practice Address - Country:US
Practice Address - Phone:217-877-0312
Practice Address - Fax:217-877-0397
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007432152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007432Medicaid
ILT37950Medicare UPIN