Provider Demographics
NPI:1740217462
Name:DAVIDSON, DAVID L (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:DAVIDSON
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 1:1235 WATER TOWER PL
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2142
Mailing Address - Country:US
Mailing Address - Phone:636-296-8612
Mailing Address - Fax:636-296-8055
Practice Address - Street 1:1235 WATER TOWER PL
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2142
Practice Address - Country:US
Practice Address - Phone:636-296-8612
Practice Address - Fax:636-296-8055
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOTO2097152W00000X, 152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO7891Medicare ID - Type Unspecified