Provider Demographics
NPI:1821266735
Name:MARK A. DAVIS, O.D.
Entity Type:Organization
Organization Name:MARK A. DAVIS, O.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:256-593-1986
Mailing Address - Street 1:510 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-1432
Mailing Address - Country:US
Mailing Address - Phone:256-593-1986
Mailing Address - Fax:256-593-1976
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-1432
Practice Address - Country:US
Practice Address - Phone:256-593-1986
Practice Address - Fax:256-593-1976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-13
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0577240001Medicare NSC