Provider Demographics
NPI:1457082356
Name:LI, DAVISSON W (OD)
Entity Type:Individual
Prefix:
First Name:DAVISSON
Middle Name:W
Last Name:LI
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 1:125 PASSAIC AVE APT 125-103
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-1137
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:160 PASSAIC AVE STE 1
Practice Address - Street 2:
Practice Address - City:KEARNY
Practice Address - State:NJ
Practice Address - Zip Code:07032-1130
Practice Address - Country:US
Practice Address - Phone:201-467-2004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-21
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00712800152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist