Provider Demographics
NPI:1447086434
Name:DAVIS, GREGORY
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:DAVIS
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 1:1024 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-2311
Mailing Address - Country:US
Mailing Address - Phone:859-885-2314
Mailing Address - Fax:859-885-5130
Practice Address - Street 1:1024 N MAIN ST
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-2311
Practice Address - Country:US
Practice Address - Phone:859-885-2314
Practice Address - Fax:859-885-5130
Is Sole Proprietor?:No
Enumeration Date:2024-09-09
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY163707156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician