MEDICARE: MARK K DAVIS & ASSOCIATES, PA

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	3460TG	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000072FC	OTHER	TX	BCBS

General Provider Information

NPI Number	:	1770765497
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MARK K DAVIS & ASSOCIATES, PA

Provider Business Mailing Address
First Line	:	6450 NW LOOP 410
Second Line	:	SUITE 115
City	:	SAN ANTONIO
State	:	TX
Zip	:	78238-4209
Country	:	US
Telephone Number	:	210-521-2085
Fax Number	:	210-509-0962

Provider Business Practice Location Address
First Line	:	6450 NW LOOP 410
Second Line	:	SUITE 115
City	:	SAN ANTONIO
State	:	TX
Zip	:	78238-4209
Country	:	US
Telephone Number	:	210-521-2085
Fax Number	:	210-509-0962

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MARK KEITH DAVIS
Credential	:	OD
Telephone Number	:	210-521-2085

Provider Enumeration Date	:	12/04/2007
Last Update Date	:	01/28/2008

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