Provider Demographics
NPI:1902987514
Name:DAVIS IV, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:DAVIS IV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:730 7TH ST
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34711-2145
Mailing Address - Country:US
Mailing Address - Phone:352-394-6168
Mailing Address - Fax:352-394-6645
Practice Address - Street 1:730 7TH ST
Practice Address - Street 2:
Practice Address - City:CLERMONT
Practice Address - State:FL
Practice Address - Zip Code:34711-2145
Practice Address - Country:US
Practice Address - Phone:352-394-6168
Practice Address - Fax:352-394-6645
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 2033152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLT84210Medicare UPIN
FL19235ZMedicare PIN
FL6228000001Medicare NSC