MEDICARE: DR. BERNETTA DAVIS OD, PLLC

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	TA0696	MD

General Provider Information

NPI Number	:	1942570874
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DR. BERNETTA DAVIS OD, PLLC

Provider Business Mailing Address
First Line	:	1804 W NORTH AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21217-1621
Country	:	US
Telephone Number	:	410-523-1224
Fax Number	:

Provider Business Practice Location Address
First Line	:	1804 W NORTH AVE
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21217-1621
Country	:	US
Telephone Number	:	410-523-1224
Fax Number	:

Authorized Official
Title or Position	:	RESIDENT AGENT
Name	:	DR. BERNETTA DAVIS-POOLE
Credential	:	OD
Telephone Number	:	410-523-1224

Provider Enumeration Date	:	01/10/2012
Last Update Date	:	03/31/2013

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