=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841342235
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK CHARLES DAVIES OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4000 NEW BOSTON RD
-----------------------------------------------------
City | TEXARKANA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-838-5666
-----------------------------------------------------
Fax | 903-831-5320
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5503 HWY 77 WEST
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75551
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-833-8566
-----------------------------------------------------
Fax | 903-831-5320
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 4185T
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------