MEDICARE: RON GLENN DAVIDSON OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2361TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V0100218	OTHER	TX	DPS

General Provider Information

NPI Number	:	1073625224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RON GLENN DAVIDSON OD

Provider Business Mailing Address
First Line	:	3000 SOUTH HULEN STREET
Second Line	:	SUITE 104
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1930
Country	:	US
Telephone Number	:	817-738-2027
Fax Number	:	817-738-5440

Provider Business Practice Location Address
First Line	:	3000 SOUTH HULEN STREET
Second Line	:	SUITE 104
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1930
Country	:	US
Telephone Number	:	817-738-2027
Fax Number	:	817-738-5440

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/31/2006
Last Update Date	:	03/07/2023

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