Provider Demographics
NPI:1235120619
Name:RICHARD M DAVIS MD PA
Entity Type:Organization
Organization Name:RICHARD M DAVIS MD PA
Other - Org Name:CYPRESS LAKE EYEWEAR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:M
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:239-481-3343
Mailing Address - Street 1:9201 CYPRESS LAKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-4941
Mailing Address - Country:US
Mailing Address - Phone:239-481-8171
Mailing Address - Fax:239-482-5227
Practice Address - Street 1:9201 CYPRESS LAKE DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-4941
Practice Address - Country:US
Practice Address - Phone:239-481-8171
Practice Address - Fax:239-482-5227
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHARD M DAVIS MD PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-03
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0000176156FX1800X
FL000176332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
18778423210OtherUNITED HEALTHCARE
0499890001OtherD MERC
6924OtherAVESIS
0499890001OtherD MERC