Provider Demographics
NPI:1902050669
Name:DAVIS, GENA LYNN (OD)
Entity Type:Individual
Prefix:
First Name:GENA
Middle Name:LYNN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1088
Mailing Address - Street 2:
Mailing Address - City:GUALALA
Mailing Address - State:CA
Mailing Address - Zip Code:95445-1088
Mailing Address - Country:US
Mailing Address - Phone:707-884-3937
Mailing Address - Fax:
Practice Address - Street 1:39150 OCEAN DRIVE
Practice Address - Street 2:SUITE 2A
Practice Address - City:GUALALA
Practice Address - State:CA
Practice Address - Zip Code:95445
Practice Address - Country:US
Practice Address - Phone:707-884-3937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-07
Last Update Date:2008-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8214T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD0082140Medicare PIN