Provider Demographics
NPI:1568148039
Name:DAVIS, THADDEUS (OD)
Entity Type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:THAD
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:400 SW SHIRLEY ST
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-2731
Mailing Address - Country:US
Mailing Address - Phone:641-208-5643
Mailing Address - Fax:
Practice Address - Street 1:560 SE BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-5505
Practice Address - Country:US
Practice Address - Phone:509-334-3300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist