Provider Demographics
NPI:1538105622
Name:DAVIS, LAWRENCE ROBERT (OD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
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 1:108 E GIRARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19125
Mailing Address - Country:US
Mailing Address - Phone:215-739-8775
Mailing Address - Fax:215-739-8775
Practice Address - Street 1:108 E GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19125
Practice Address - Country:US
Practice Address - Phone:215-739-8775
Practice Address - Fax:215-739-8775
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE005224T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000839887001Medicaid
DA033740Medicare PIN
0336380001Medicare NSC
T27208Medicare UPIN