Provider Demographics
NPI:1477558302
Name:DAVIS, VIKTORIA LARSON (OD)
Entity Type:Individual
Prefix:DR
First Name:VIKTORIA
Middle Name:LARSON
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MISS
Other - First Name:VIKTORIA
Other - Middle Name:JANET
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:MADELIA
Mailing Address - State:MN
Mailing Address - Zip Code:56062-0190
Mailing Address - Country:US
Mailing Address - Phone:507-642-3853
Mailing Address - Fax:507-642-3854
Practice Address - Street 1:18 BENZEL AVE NW
Practice Address - Street 2:
Practice Address - City:MADELIA
Practice Address - State:MN
Practice Address - Zip Code:56062-1422
Practice Address - Country:US
Practice Address - Phone:507-642-3853
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2730152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN136600900Medicaid
MN288R1DAOtherBLUE CROSS BLUE SHIELD OF MN
MN136600900Medicaid
MN288R1DAOtherBLUE CROSS BLUE SHIELD OF MN