Provider Demographics
NPI:1275537672
Name:DAVIS, BRIAN J (OD)
Entity Type:Individual
Prefix:
First Name:BRIAN
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 1:2685 BECKY THATCHER RD
Mailing Address - Street 2:
Mailing Address - City:MUSCATINE
Mailing Address - State:IA
Mailing Address - Zip Code:52761-9700
Mailing Address - Country:US
Mailing Address - Phone:563-263-4011
Mailing Address - Fax:
Practice Address - Street 1:1700 PARK AVE
Practice Address - Street 2:
Practice Address - City:MUSCATINE
Practice Address - State:IA
Practice Address - Zip Code:52761-5434
Practice Address - Country:US
Practice Address - Phone:563-263-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-13
Last Update Date:2012-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1816152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4222836Medicaid
IA3222836Medicaid
IAI1161Medicare PIN
IA410041837Medicare PIN
IAT01270Medicare UPIN
IA410048194Medicare PIN
IA22283Medicare PIN