Provider Demographics
NPI:1568148039
Name:DAVIS, THADDEUS (OD)
Entity type:Individual
Prefix:
First Name:THADDEUS
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:THAD
Other - Middle Name:
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:955 W SOUTHERN AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85210-4903
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-893-8172
Practice Address - Street 1:610 E BASELINE RD STE C3
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85042-6536
Practice Address - Country:US
Practice Address - Phone:602-269-9771
Practice Address - Fax:602-268-0899
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-27
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD61467516152W00000X
IDODP-100630152W00000X
AZOPT-00779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist