Provider Demographics
NPI:1629349857
Name:GARY DAVIDSON OD INC
Entity Type:Organization
Organization Name:GARY DAVIDSON OD INC
Other - Org Name:DR GARY E DAVIDSON, OD
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:502-895-4456
Mailing Address - Street 1:734 BROWNS LN
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4007
Mailing Address - Country:US
Mailing Address - Phone:502-895-4456
Mailing Address - Fax:502-966-9347
Practice Address - Street 1:4803 OUTER LOOP DRIVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40219-3200
Practice Address - Country:US
Practice Address - Phone:502-964-7726
Practice Address - Fax:502-966-9347
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0886DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY819777OtherEYEMED
KY410006446OtherRR MEDICARE
KY911200OtherBLOCK VISION
KYT54705OtherUPIN
KY5310609OtherAETNA
KY77008860Medicaid
KY181046OtherNVA
KYZKY33088OtherINGENIX
KY000000042951OtherKY BLUE SHIELD
KY819777OtherCOLE VISION SERVICES
KY181046OtherNVA