Provider Demographics
NPI:1588756217
Name:DAVIS-POOLE, BERNETTA WINFRED (OD)
Entity type:Individual
Prefix:DR
First Name:BERNETTA
Middle Name:WINFRED
Last Name:DAVIS-POOLE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:BERNETTA
Other - Middle Name:WINFRED
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:1804 WEST NORTH AVENUE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21217
Mailing Address - Country:US
Mailing Address - Phone:410-523-1224
Mailing Address - Fax:410-728-1804
Practice Address - Street 1:1804 WEST NORTH AVENUE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21217
Practice Address - Country:US
Practice Address - Phone:410-523-1224
Practice Address - Fax:410-747-6563
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA0696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD790418504Medicaid
MD790418501Medicaid
P00870154OtherMEDICARE PROVIDER #
MD3325172 00Medicaid
MD790418504Medicaid