Basic Information
| Provider Information | |||||||||
| NPI: | 1053330712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | GEORGE | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 705 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208871151 | ||||||||
| FaxNumber: | 9208873353 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 S UNIVERSITY AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | BEAVER DAM | ||||||||
| State: | WI | ||||||||
| PostalCode: | 539163053 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9208871151 | ||||||||
| FaxNumber: | 9208873353 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 05/16/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 21978 | WI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
ID Information
| ID | Type | State | Issuer | Description | 180012216 | 01 | WI | RAIL ROAD MEDICARE | OTHER | 1003606 | 01 | WI | PHYSICIANS PLUS HMO | OTHER | 180012216 | 01 | RAIL ROAD MEDICARE | OTHER | 7746 | 01 | WI | NETWORK HEALTH PLAN | OTHER | 934 | 01 | WI | DEAN CARE HMO | OTHER | WI0101 | 01 | JOHN DEERE HEALTH PLAN | OTHER | 30404100 | 05 | WI | MEDICAID | 39115615602 | 01 | WI | UNITY HMO | OTHER |