Provider Demographics
NPI:1942570874
Name:DR. BERNETTA DAVIS OD, PLLC
Entity Type:Organization
Organization Name:DR. BERNETTA DAVIS OD, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RESIDENT AGENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BERNETTA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS-POOLE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:410-523-1224
Mailing Address - Street 1:1804 W NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217-1621
Mailing Address - Country:US
Mailing Address - Phone:410-523-1224
Mailing Address - Fax:
Practice Address - Street 1:1804 W NORTH AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217-1621
Practice Address - Country:US
Practice Address - Phone:410-523-1224
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-10
Last Update Date:2013-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD242481Medicare PIN