Provider Demographics
NPI:1841342235
Name:DAVIES, MARK CHARLES (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:CHARLES
Last Name:DAVIES
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 1:5503 HWY 77 WEST
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:TX
Mailing Address - Zip Code:75551
Mailing Address - Country:US
Mailing Address - Phone:903-833-8566
Mailing Address - Fax:903-831-5320
Practice Address - Street 1:4000 NEW BOSTON RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501
Practice Address - Country:US
Practice Address - Phone:903-838-5666
Practice Address - Fax:903-831-5320
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4185T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00E68SMedicare ID - Type Unspecified
U47512Medicare UPIN