Provider Demographics
NPI:1871522235
Name:DAVIS, STEVEN O (OD)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:O
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 1:622 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:ID
Mailing Address - Zip Code:83644-3080
Mailing Address - Country:US
Mailing Address - Phone:208-585-9500
Mailing Address - Fax:208-585-9497
Practice Address - Street 1:622 E MAIN ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:ID
Practice Address - Zip Code:83644-3080
Practice Address - Country:US
Practice Address - Phone:208-585-9500
Practice Address - Fax:208-585-9497
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO868152W00000X
IDODP-100237152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U22657Medicare UPIN