Provider Demographics
NPI:1659347698
Name:DAVIS, JEFFREY K (OD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:K
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 1:2922 JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:MARIANNA
Mailing Address - State:FL
Mailing Address - Zip Code:32446-3448
Mailing Address - Country:US
Mailing Address - Phone:850-526-4550
Mailing Address - Fax:850-526-1200
Practice Address - Street 1:2922 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MARIANNA
Practice Address - State:FL
Practice Address - Zip Code:32446-3448
Practice Address - Country:US
Practice Address - Phone:850-526-4550
Practice Address - Fax:850-526-1200
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1631152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL19997OtherBCBS
FL078183500Medicaid
FL410000203OtherRAILROAD MEDICARE
FLK6143OtherPC-ACE PRO 32
FL410000203OtherRAILROAD MEDICARE
FL19997Medicare PIN