Provider Demographics
NPI:1275513509
Name:DAVIS, ROBERT L (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:L
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 1:4663 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-2540
Mailing Address - Country:US
Mailing Address - Phone:708-636-0600
Mailing Address - Fax:708-636-0606
Practice Address - Street 1:4663 W 95TH ST
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2540
Practice Address - Country:US
Practice Address - Phone:708-636-0600
Practice Address - Fax:708-636-0606
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007176152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1265621361OtherGROUP NPI NUMBER
IL506370OtherMEDICARE GROUP NUMBER
IL046007173Medicaid
IL506370OtherMEDICARE GROUP NUMBER
IL046007173Medicaid