=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831256726
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVIS OPTOMETRY GROUP PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 05/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2922 JEFFERSON ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-526-4550
-----------------------------------------------------
Fax | 850-526-1200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2922 JEFFERSON ST
-----------------------------------------------------
City | MARIANNA
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32446-3448
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 850-526-4550
-----------------------------------------------------
Fax | 850-526-1200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. ROBIN MARY MEDINA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 850-526-4550
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------