MEDICARE: DR. JADE NGOC MY DAVIS O.D.

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	11765T	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457303398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JADE NGOC MY DAVIS O.D.

Provider Business Mailing Address
First Line	:	343 S BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-1207
Country	:	US
Telephone Number	:	213-626-9978
Fax Number	:	213-628-0500

Provider Business Practice Location Address
First Line	:	343 S BROADWAY
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90013-1207
Country	:	US
Telephone Number	:	213-626-9978
Fax Number	:	213-628-0500

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

Provider Enumeration Date	:	05/17/2006
Last Update Date	:	07/08/2007

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