Provider Demographics
NPI:1386846913
Name:RON G DAVIDSON, OD PC DBA EYES NOUVEAU
Entity Type:Organization
Organization Name:RON G DAVIDSON, OD PC DBA EYES NOUVEAU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DOROTHY
Authorized Official - Middle Name:C
Authorized Official - Last Name:ANGUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-738-2027
Mailing Address - Street 1:3000 S HULEN ST
Mailing Address - Street 2:SUITE 104
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76109-1929
Mailing Address - Country:US
Mailing Address - Phone:817-738-2027
Mailing Address - Fax:817-738-5440
Practice Address - Street 1:3000 S HULEN ST
Practice Address - Street 2:SUITE 104
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76109-1929
Practice Address - Country:US
Practice Address - Phone:817-738-2027
Practice Address - Fax:817-738-5440
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RON G DAVIDSON OD PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-06-05
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2361TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00990NMedicare PIN