Healthcare Provider Details

I. General information

NPI: 1235120619
Provider Name (Legal Business Name): RICHARD M DAVIS MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 06/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9201 CYPRESS LAKE DR
FORT MYERS FL
33919-4941
US

IV. Provider business mailing address

9201 CYPRESS LAKE DR
FORT MYERS FL
33919-4941
US

V. Phone/Fax

Practice location:
  • Phone: 239-481-8171
  • Fax: 239-482-5227
Mailing address:
  • Phone: 239-481-8171
  • Fax: 239-482-5227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number0000176
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number000176
License Number StateFL

VIII. Authorized Official

Name: MR. RICHARD M DAVIS
Title or Position: PRESIDENT
Credential: MD
Phone: 239-481-3343