Provider Demographics
NPI:1457303398
Name:DAVIS, JADE NGOC MY (OD)
Entity Type:Individual
Prefix:DR
First Name:JADE
Middle Name:NGOC MY
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JADE
Other - Middle Name:NGOC MY
Other - Last Name:TRINH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:343 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90013-1207
Mailing Address - Country:US
Mailing Address - Phone:213-626-9978
Mailing Address - Fax:213-628-0500
Practice Address - Street 1:343 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1207
Practice Address - Country:US
Practice Address - Phone:213-626-9978
Practice Address - Fax:213-628-0500
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11765T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0117650Medicaid
CASD0117650Medicaid
CAOP11765Medicare ID - Type Unspecified