Provider Demographics
NPI:1124154505
Name:DAVIS, MARK A (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:A
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 1:510 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOAZ
Mailing Address - State:AL
Mailing Address - Zip Code:35957-1432
Mailing Address - Country:US
Mailing Address - Phone:256-593-1986
Mailing Address - Fax:256-593-1976
Practice Address - Street 1:510 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BOAZ
Practice Address - State:AL
Practice Address - Zip Code:35957-1432
Practice Address - Country:US
Practice Address - Phone:256-593-1986
Practice Address - Fax:256-593-1976
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-27
Last Update Date:2008-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-532-TA-292152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000058419Medicare PIN
ALT69178Medicare UPIN