Active NPI
Glenn Davis, MD
- Ophthalmology Physician
- Pulaski, VA
National Provider Identifier
1083724512
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Ophthalmology Physician
- License
- 0101036189
- Practice address
- 1510 Bob White Blvd
Pulaski, VA 24301-4406 - Phone
- (540) 980-1965
- Fax
- (540) 980-0032
- NPI assigned
- Aug 30, 2006
- Last updated
- Oct 11, 2013
- Sex
- Male
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Ophthalmology Physician | 207W00000X | 0101036189 | VA | Primary |
Addresses
Primary practice location
1510 Bob White Blvd
Pulaski, VA 24301-4406
Mailing address
1510 Bob White Blvd
Pulaski, VA 24301-4406
Phone (540) 980-1965
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 010104238 | Medicaid | VA | |
| 010126991 | Medicaid | VA |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in VA
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: Yes
- Hospice: Yes
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20040602000752 | VA | Practitioner - Ophthalmology | 3678555869 |
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Doctor of Medicine
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 0101036189 | VA | MD | Ophthalmology Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1156896000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1381449600000",
"number": "1083724512",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1510 BOB WHITE BLVD",
"city": "PULASKI",
"state": "VA",
"postal_code": "243014406",
"telephone_number": "540-980-1965",
"fax_number": "540-980-0032"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1510 BOB WHITE BLVD",
"city": "PULASKI",
"state": "VA",
"postal_code": "243014406",
"telephone_number": "540-980-1965",
"fax_number": "540-980-0032"
}
],
"practiceLocations": [],
"basic": {
"last_name": "DAVIS",
"first_name": "GLENN",
"credential": "MD",
"sole_proprietor": "NO",
"sex": "M",
"enumeration_date": "2006-08-30",
"last_updated": "2013-10-11",
"status": "A"
},
"taxonomies": [
{
"code": "207W00000X",
"taxonomy_group": "",
"desc": "Ophthalmology",
"state": "VA",
"license": "0101036189",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "010104238",
"state": "VA"
},
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "010126991",
"state": "VA"
}
],
"endpoints": [],
"other_names": []
}Other providers in Pulaski, VA
- Commonwealth of Virginia State Board of Health (Pulaski County Health Department)
- Tyreese Conquest
- Raymond Ibarra Cruz, MD
- Benjamin Scott Davidson, M.D.
- Crystal M Davis, FNP-BC
- Linda Sue Davis, RN, GCNS-BC
- Dignified Transport Service LLC
- Erin H Dove, M.D.
- Ann Dianese Lee Edmonds
- Molly G Edwards, FNP-C
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 11, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.