MEDICARE: RON G DAVIDSON, OD PC DBA EYES NOUVEAU

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	TN

General Provider Information

NPI Number	:	1386846913
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RON G DAVIDSON, OD PC DBA EYES NOUVEAU

Provider Business Mailing Address
First Line	:	3000 S HULEN ST
Second Line	:	SUITE 104
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1929
Country	:	US
Telephone Number	:	817-738-2027
Fax Number	:	817-738-5440

Provider Business Practice Location Address
First Line	:	3000 S HULEN ST
Second Line	:	SUITE 104
City	:	FORT WORTH
State	:	TX
Zip	:	76109-1929
Country	:	US
Telephone Number	:	817-738-2027
Fax Number	:	817-738-5440

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	DOROTHY C ANGUS
Credential	:
Telephone Number	:	817-738-2027

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	11/11/2008

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