MEDICARE: BRIAN WALTER DAVIS 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	1028	NV
2	152W00000X	Optometrist	ODP100516	ID

General Provider Information

NPI Number	:	1689234601
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIAN WALTER DAVIS OD

Provider Business Mailing Address
First Line	:	4270 N EAGLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-0726
Country	:	US
Telephone Number	:	208-938-2010
Fax Number	:	208-938-2011

Provider Business Practice Location Address
First Line	:	4270 N EAGLE RD
Second Line	:
City	:	BOISE
State	:	ID
Zip	:	83713-0726
Country	:	US
Telephone Number	:	208-938-2010
Fax Number	:	208-938-2011

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

Provider Enumeration Date	:	06/20/2019
Last Update Date	:	05/02/2022

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