Provider Demographics
NPI:1972701084
Name:CAROLYN J. DAVIS
Entity type:Organization
Organization Name:CAROLYN J. DAVIS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:937-339-7956
Mailing Address - Street 1:19 S WESTON RD
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-2515
Mailing Address - Country:US
Mailing Address - Phone:937-339-7956
Mailing Address - Fax:937-339-6860
Practice Address - Street 1:19 S WESTON RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-2515
Practice Address - Country:US
Practice Address - Phone:937-339-7956
Practice Address - Fax:937-339-6860
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-10
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4494152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH7402675OtherAETNA
OH7402675OtherAETNA
OHCA9319711Medicare PIN