Provider Demographics
NPI:1891880548
Name:DAVIS, STACY L (OD)
Entity Type:Individual
Prefix:DR
First Name:STACY
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:6739 FULTON ST E
Mailing Address - Street 2:STE A-20
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-8138
Mailing Address - Country:US
Mailing Address - Phone:616-676-2015
Mailing Address - Fax:616-676-2011
Practice Address - Street 1:6739 FULTON ST E
Practice Address - Street 2:STE A-20
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-8138
Practice Address - Country:US
Practice Address - Phone:616-676-2015
Practice Address - Fax:616-676-2011
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2010-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4901003961152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist