Provider Demographics
NPI:1497051858
Name:STALEY, DAVIS MARSHALL
Entity Type:Individual
Prefix:
First Name:DAVIS
Middle Name:MARSHALL
Last Name:STALEY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 W DIMOND BLVD
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99515-1903
Mailing Address - Country:US
Mailing Address - Phone:907-267-7102
Mailing Address - Fax:907-349-7039
Practice Address - Street 1:330 W DIMOND BLVD
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99515-1903
Practice Address - Country:US
Practice Address - Phone:907-267-7102
Practice Address - Fax:907-349-7039
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK106884152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
920086076OtherTAX ID