Provider Demographics
NPI:1497716088
Name:DAVIS, MITCHELL ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:MITCHELL
Middle Name:ROBERT
Last Name:DAVIS
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 1:376 E PENN DR
Mailing Address - Street 2:
Mailing Address - City:ENOLA
Mailing Address - State:PA
Mailing Address - Zip Code:17025-2158
Mailing Address - Country:US
Mailing Address - Phone:717-732-2423
Mailing Address - Fax:717-732-6780
Practice Address - Street 1:376 E PENN DR
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-2158
Practice Address - Country:US
Practice Address - Phone:717-732-2423
Practice Address - Fax:717-732-6780
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-31
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UO8102Medicare UPIN
0415080001Medicare NSC
PA289990Medicare PIN
580001646Medicare PIN