Provider Demographics
NPI:1336367937
Name:DAVIS, STEPHANIE MICHELE (OD)
Entity Type:Individual
Prefix:DR
First Name:STEPHANIE
Middle Name:MICHELE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:STEPHANIE
Other - Middle Name:MICHELE
Other - Last Name:DOLLAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:430 VICKSBURG DR
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77351-9575
Mailing Address - Country:US
Mailing Address - Phone:936-328-5600
Mailing Address - Fax:936-328-8601
Practice Address - Street 1:200 OGLETREE DR
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:TX
Practice Address - Zip Code:77351-6420
Practice Address - Country:US
Practice Address - Phone:936-328-5600
Practice Address - Fax:936-328-8601
Is Sole Proprietor?:No
Enumeration Date:2007-04-22
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5938TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX82229QOtherBLUE CROSS BLUE SHIELD
TX82229QOtherBLUE CROSS BLUE SHIELD
TX81520Medicare UPIN