Provider Demographics
NPI:1336460864
Name:CAROL E DAVIS, M.D. MEDICAL CLINIC OF OPHTHALMOLOGY, INC.
Entity Type:Organization
Organization Name:CAROL E DAVIS, M.D. MEDICAL CLINIC OF OPHTHALMOLOGY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-564-6507
Mailing Address - Street 1:1807 WILSHIRE BLVD
Mailing Address - Street 2:STE. 203
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90403-5652
Mailing Address - Country:US
Mailing Address - Phone:310-829-0160
Mailing Address - Fax:310-829-0170
Practice Address - Street 1:1807 WILSHIRE BLVD
Practice Address - Street 2:STE. 203
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5652
Practice Address - Country:US
Practice Address - Phone:310-829-0160
Practice Address - Fax:310-829-0170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2010-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50376207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89914Medicare UPIN