Provider Demographics
NPI:1174633564
Name:DAVIS, LARRY JON (OD)
Entity type:Individual
Prefix:DR
First Name:LARRY
Middle Name:JON
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:ONE UNIVERSITY BLVD
Mailing Address - Street 2:PATIENT CARE CENTER
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63121
Mailing Address - Country:US
Mailing Address - Phone:314-516-5131
Mailing Address - Fax:314-516-5507
Practice Address - Street 1:7840 NATURAL BRIDGE
Practice Address - Street 2:PATIENT CARE CENTER
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63121
Practice Address - Country:US
Practice Address - Phone:314-516-5131
Practice Address - Fax:314-516-5507
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOT02724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1174633564Medicaid
MO1174633564Medicaid
MO074730012Medicare PIN
MO067820009Medicare PIN
MO067820009Medicare PIN