Provider Demographics
NPI:1881666014
Name:DAVIS, MARK LEROY (OD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:LEROY
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 1:3333 DUBUQUE AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-2767
Mailing Address - Country:US
Mailing Address - Phone:515-630-2875
Mailing Address - Fax:515-630-2876
Practice Address - Street 1:3333 DUBUQUE AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-2767
Practice Address - Country:US
Practice Address - Phone:515-630-2875
Practice Address - Fax:156-302-8765
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1888152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA28826OtherBLUE CROSS BLUE SHIELD
IAP00400423OtherMEDICARE RAILROAD
IA0288266Medicaid
IA5914940001Medicare NSC
IAI19926Medicare PIN
IA28826OtherBLUE CROSS BLUE SHIELD