Provider Demographics
NPI:1023261435
Name:DAVIS, MICHAEL RAY (LDO)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:RAY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 N 40TH AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98908-4318
Mailing Address - Country:US
Mailing Address - Phone:509-966-4735
Mailing Address - Fax:509-966-4755
Practice Address - Street 1:506 N 40TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98908-4318
Practice Address - Country:US
Practice Address - Phone:509-966-4735
Practice Address - Fax:509-966-4755
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADO 00001859156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA6233530001Medicare NSC