MEDICARE: DR. SHANNON DAVIDSON OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	5704	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023209350
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SHANNON DAVIDSON OD

Provider Business Mailing Address
First Line	:	1001 W FIFTH ST
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040
Country	:	US
Telephone Number	:	937-644-8637
Fax Number	:	937-644-8653

Provider Business Practice Location Address
First Line	:	1001 W FIFTH ST
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040
Country	:	US
Telephone Number	:	937-644-8637
Fax Number	:	937-644-8653

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2007
Last Update Date	:	07/23/2013

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