Provider Demographics
NPI:1003814179
Name:DAVID, MICHAEL D (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:DAVID
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3810
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64803-3810
Mailing Address - Country:US
Mailing Address - Phone:417-347-2273
Mailing Address - Fax:417-347-2277
Practice Address - Street 1:1130 E 32ND ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4034
Practice Address - Country:US
Practice Address - Phone:417-347-2273
Practice Address - Fax:417-347-2277
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3714207Q00000X
IADO05122207Q00000X
MO2021010406207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100197510EMedicaid
OK200470610DOtherOSU-GROUP
OK100197510COtherOSU-INDIVIDUAL
OK200505990BMedicaid
OK900522214Medicare PIN
OK200505990BMedicaid
OK481098370002OtherBCBS