Provider Demographics
NPI:1689896003
Name:DAVIS EYE ASSOCIATES OD, PA
Entity Type:Organization
Organization Name:DAVIS EYE ASSOCIATES OD, PA
Other - Org Name:DBA FAMILY VISION CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:G
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:336-765-5350
Mailing Address - Street 1:3316 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3011
Mailing Address - Country:US
Mailing Address - Phone:336-765-5350
Mailing Address - Fax:336-765-0769
Practice Address - Street 1:4514 OLEANDER DR
Practice Address - Street 2:FAMILY VISION CLINIC
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5012
Practice Address - Country:US
Practice Address - Phone:910-392-4414
Practice Address - Fax:910-392-3153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916158Medicaid
NC5916158Medicaid