Provider Demographics
NPI:1558379206
Name:DAVIS, EDWARD WATTS (OD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:WATTS
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:PO BOX 648
Mailing Address - Street 2:1431 WEST 10TH STREET SUITE 5
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0648
Mailing Address - Country:US
Mailing Address - Phone:601-649-1437
Mailing Address - Fax:601-649-1431
Practice Address - Street 1:1431 W 10TH ST STE 5
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-2626
Practice Address - Country:US
Practice Address - Phone:601-649-1437
Practice Address - Fax:601-649-1431
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS415152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880157Medicaid
MS640478560OtherTIN
MS640478560OtherTIN
MS410000054Medicare ID - Type Unspecified