Provider Demographics
NPI:1891810669
Name:DAVIS, VAN A (OD)
Entity Type:Individual
Prefix:DR
First Name:VAN
Middle Name:A
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 1:1013 N 5TH AVE NE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-2664
Mailing Address - Country:US
Mailing Address - Phone:706-291-7360
Mailing Address - Fax:706-291-8655
Practice Address - Street 1:1013 N 5TH AVE NE
Practice Address - Street 2:SUITE 3
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-2664
Practice Address - Country:US
Practice Address - Phone:706-291-7360
Practice Address - Fax:706-291-8655
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1829152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000941762BMedicaid
GAGRP2997Medicare PIN
GAU78682Medicare UPIN
GA000941762BMedicaid