Provider Demographics
NPI:1366492357
Name:DAVIS, JAMES E JR (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:E
Last Name:DAVIS
Suffix:JR
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 1:3411 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
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046007432152W00000X
IN18002009B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046007432Medicaid
IN18002009BOtherOPTOMETRY LICENSE
MD0221236OtherDEA NUMBER
MD0221236OtherDEA NUMBER
IL046007432Medicaid