Provider Demographics
NPI:1881869618
Name:GLENN K DAVIS II MD PC
Entity type:Organization
Organization Name:GLENN K DAVIS II MD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:BYRD
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:540-980-1965
Mailing Address - Street 1:1510 BOB WHITE BLVD
Mailing Address - Street 2:
Mailing Address - City:PULASKI
Mailing Address - State:VA
Mailing Address - Zip Code:24301-4406
Mailing Address - Country:US
Mailing Address - Phone:540-980-1965
Mailing Address - Fax:540-980-0032
Practice Address - Street 1:1510 BOB WHITE BLVD
Practice Address - Street 2:
Practice Address - City:PULASKI
Practice Address - State:VA
Practice Address - Zip Code:24301-4406
Practice Address - Country:US
Practice Address - Phone:540-980-1965
Practice Address - Fax:540-980-0032
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-23
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036189207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010126991Medicaid
VA010104238Medicaid
VA010104238Medicaid
VAC09033Medicare PIN