Provider Demographics
NPI:1881660827
Name:DAVIS, MARION BERT JR (OD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:BERT
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:M
Other - Middle Name:BERT
Other - Last Name:DAVIS
Other - Suffix:JR
Other - Last Name Type:Professional Name
Other - Credentials:OD
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:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC1401152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6143OtherPC-ACE PRO 32
FL078126600Medicaid
FL410016448OtherRAILROAD MEDICARE
FL410016448OtherRR MEDICARE
FL19031OtherBC/BS
FL410016448OtherRAILROAD MEDICARE
FL19031OtherBC/BS