Provider Demographics
NPI:1255097564
Name:DAVIS, ODIS
Entity type:Individual
Prefix:
First Name:ODIS
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 SUNSET BLVD APT 7304
Mailing Address - Street 2:
Mailing Address - City:ROWLETT
Mailing Address - State:TX
Mailing Address - Zip Code:75088-1272
Mailing Address - Country:US
Mailing Address - Phone:469-925-8575
Mailing Address - Fax:
Practice Address - Street 1:8400 SUNSET BLVD APT 7304
Practice Address - Street 2:
Practice Address - City:ROWLETT
Practice Address - State:TX
Practice Address - Zip Code:75088-1272
Practice Address - Country:US
Practice Address - Phone:469-925-8575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX216034224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant