Provider Demographics
NPI:1164420352
Name:DAVIS, MICHELE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHELE
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:614 CRANBURY RD UNIT 81
Mailing Address - Street 2:
Mailing Address - City:EAST BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08816-8004
Mailing Address - Country:US
Mailing Address - Phone:908-451-5362
Mailing Address - Fax:
Practice Address - Street 1:614 CRANBURY RD UNIT 81
Practice Address - Street 2:
Practice Address - City:EAST BRUNSWICK
Practice Address - State:NJ
Practice Address - Zip Code:08816-8004
Practice Address - Country:US
Practice Address - Phone:908-360-5362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-12
Last Update Date:2018-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY236461207Q00000X, 207Q00000X
NJ25MB07472100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
I17102Medicare UPIN