Provider Demographics
NPI:1487345443
Name:DAVIS, TOMMY LEE II
Entity type:Individual
Prefix:
First Name:TOMMY
Middle Name:LEE
Last Name:DAVIS
Suffix:II
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 1:2125 NW STEWART PKWY
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-1693
Mailing Address - Country:US
Mailing Address - Phone:541-957-8552
Mailing Address - Fax:541-957-8549
Practice Address - Street 1:2125 NW STEWART PKWY
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-1693
Practice Address - Country:US
Practice Address - Phone:541-957-8552
Practice Address - Fax:541-957-8549
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR250110156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician