Basic Information
Provider Information | |||||||||
NPI: | 1689110785 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIDSON | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | OD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WARNE | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | OD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 8325 SW 157TH ST | ||||||||
Address2: |   | ||||||||
City: | PALMETTO BAY | ||||||||
State: | FL | ||||||||
PostalCode: | 331572165 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4043759311 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | MARTIN LUTHER KING JR., CLINICA CAMPESINA | ||||||||
Address2: | 810 WEST MOWRY DR. | ||||||||
City: | HOMESTEAD | ||||||||
State: | FL | ||||||||
PostalCode: | 33030 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3052544334 | ||||||||
FaxNumber: | 3052451161 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/12/2017 | ||||||||
LastUpdateDate: | 08/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | OPT003220 | GA | N |   | Eye and Vision Services Providers | Optometrist |   | 152W00000X | 5304 | FL | Y |   | Eye and Vision Services Providers | Optometrist |   |
No ID Information.