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General NPI Number Information
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NPI Number | 1942570874
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Entity Type | Organization
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Legal Business Name | DR. BERNETTA DAVIS OD, PLLC
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Dates
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Enumeration Date | 01/10/2012
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Last Update Date | 03/31/2013
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Provider Practice Location Address
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Address Line | 1804 W NORTH AVE
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City | BALTIMORE
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State | MD
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Zip | 21217-1621
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Country | US
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Telephone | 410-523-1224
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Fax |
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Provider Business Mailing Address
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Address Line | 1804 W NORTH AVE
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City | BALTIMORE
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State | MD
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Zip | 21217-1621
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Country | US
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Telephone | 410-523-1224
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Fax |
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Authorized Official
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Title or Position | RESIDENT AGENT
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Name | DR. BERNETTA DAVIS-POOLE
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Credential | OD
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Telephone | 410-523-1224
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | TA0696
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License Number State | MD
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