Provider Demographics
NPI:1164533485
Name:DAVIS, JAMES A (OD)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SOUTH LINCOLN
Mailing Address - Street 2:
Mailing Address - City:JEROME
Mailing Address - State:ID
Mailing Address - Zip Code:83338-2624
Mailing Address - Country:US
Mailing Address - Phone:208-324-4363
Mailing Address - Fax:208-324-8948
Practice Address - Street 1:201 SOUTH LINCOLN
Practice Address - Street 2:
Practice Address - City:JEROME
Practice Address - State:ID
Practice Address - Zip Code:83338-2624
Practice Address - Country:US
Practice Address - Phone:208-324-4363
Practice Address - Fax:208-324-8948
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP0912152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002457802Medicaid
U54881Medicare UPIN
410041426Medicare ID - Type UnspecifiedRAILROAD
ID002457802Medicaid