Provider Demographics
NPI:1427108430
Name:DAVIS, MARK COLLINS (OD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:COLLINS
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 1:2820 E BELTLINE LN NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-9432
Mailing Address - Country:US
Mailing Address - Phone:616-363-5413
Mailing Address - Fax:616-363-4211
Practice Address - Street 1:2820 E BELTLINE LN NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-9432
Practice Address - Country:US
Practice Address - Phone:616-363-5413
Practice Address - Fax:616-363-4211
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002801152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT33052Medicare UPIN
MIOD14801Medicare ID - Type Unspecified