Provider Demographics
NPI:1568457489
Name:DAVIS, PATRICIA L (MD)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3100 OGDEN AVE
Mailing Address - Street 2:
Mailing Address - City:LISLE
Mailing Address - State:IL
Mailing Address - Zip Code:60532-1603
Mailing Address - Country:US
Mailing Address - Phone:630-527-1920
Mailing Address - Fax:630-527-0125
Practice Address - Street 1:3100 OGDEN AVE
Practice Address - Street 2:
Practice Address - City:LISLE
Practice Address - State:IL
Practice Address - Zip Code:60532-1603
Practice Address - Country:US
Practice Address - Phone:630-245-0989
Practice Address - Fax:630-527-0125
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-16
Last Update Date:2010-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA036092480207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036092480Medicaid
IL036092480Medicaid
IL539150Medicare PIN
ILF30236Medicare UPIN
IL539150Medicare ID - Type Unspecified