Provider Demographics
NPI:1629147137
Name:DAVISON, RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:DAVISON
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 1:4301 W WISCONSIN AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8605
Mailing Address - Country:US
Mailing Address - Phone:920-731-6116
Mailing Address - Fax:920-731-6119
Practice Address - Street 1:4301 W WISCONSIN AVE
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54913-8605
Practice Address - Country:US
Practice Address - Phone:920-731-6116
Practice Address - Fax:920-731-6119
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1993152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39788727OtherTAX ID