Healthcare Provider Details

I. General information

NPI: 1104840578
Provider Name (Legal Business Name): LISA N DAVIS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 06/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

235 HARVEY ST
WINSTON SALEM NC
27103-1741
US

IV. Provider business mailing address

3316 SILAS CREEK PKWY
WINSTON SALEM NC
27103-3011
US

V. Phone/Fax

Practice location:
  • Phone: 336-842-0952
  • Fax: 336-793-3475
Mailing address:
  • Phone: 336-765-5350
  • Fax: 336-765-0769

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WC0802X
TaxonomyCorneal and Contact Management Optometrist
License Number1285
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier7909119
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: