Basic Information
| Provider Information | |||||||||
| NPI: | 1699760603 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | KEITH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6603 FM 2920 RD | ||||||||
| Address2: | SPRING KLEIN VISION CENTER | ||||||||
| City: | SPRING | ||||||||
| State: | TX | ||||||||
| PostalCode: | 773792636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2813704444 | ||||||||
| FaxNumber: | 2813202012 | ||||||||
| Practice Location | |||||||||
| Address1: | 1742 N LOOP 1604 E | ||||||||
| Address2: | SUITE 118 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782321593 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104039050 | ||||||||
| FaxNumber: | 2104039939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/15/2005 | ||||||||
| LastUpdateDate: | 11/06/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/23/2006 | ||||||||
| NPIReactivationDate: | 03/28/2006 | ||||||||
| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 3460TG | TX | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 00000072FC | 01 | TX | BCBS | OTHER | 161053701 | 05 | TX | MEDICAID | 80575Q | 01 | TX | BCBS | OTHER | 200122447 | 01 | TX | AETNA | OTHER | 100404603 | 05 | TX | MEDICAID | 136734195824 | 01 | TX | HUMANA | OTHER | 200122447 | 01 | TX | UNITED HEALTH CARE | OTHER |