Provider Demographics
NPI:1942378468
Name:DAVIS, KRISTA M (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:KRISTA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 HIGHWAY 169 N
Mailing Address - Street 2:FOUR SEASONS EYECARE
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55442-2897
Mailing Address - Country:US
Mailing Address - Phone:763-559-7358
Mailing Address - Fax:
Practice Address - Street 1:4455 HIGHWAY 169 N
Practice Address - Street 2:FOUR SEASONS EYECARE
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55442-2897
Practice Address - Country:US
Practice Address - Phone:763-559-7358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001376152W00000X
MN2577152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U67107Medicare UPIN