Provider Demographics
NPI:1457411456
Name:DAVIS, ROGER (OD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11103 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78213-1370
Mailing Address - Country:US
Mailing Address - Phone:210-524-6803
Mailing Address - Fax:210-524-6587
Practice Address - Street 1:2950 E TEXAS ST STE 302
Practice Address - Street 2:#24
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-3259
Practice Address - Country:US
Practice Address - Phone:318-742-8896
Practice Address - Fax:318-742-8898
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA636152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist