Provider Demographics
NPI:1225031693
Name:DAVIS, MICHAEL STEVEN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:STEVEN
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 COTTAGE AVE
Mailing Address - Street 2:STE 203
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-4935
Mailing Address - Country:US
Mailing Address - Phone:209-825-5864
Mailing Address - Fax:209-825-2632
Practice Address - Street 1:200 COTTAGE AVE
Practice Address - Street 2:STE 203
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4935
Practice Address - Country:US
Practice Address - Phone:209-825-5864
Practice Address - Fax:209-825-2632
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2009-11-23
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-27
Provider Licenses
StateLicense IDTaxonomies
CAA41457207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A414570OtherMEDICARE PTAN
CA00A414570OtherMEDICARE PTAN