Provider Demographics
NPI:1235441627
Name:DAVIS, MICHAEL ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ANTHONY
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 W ARBOR DR
Mailing Address - Street 2:MAIL CODE: 0834
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-9000
Mailing Address - Country:US
Mailing Address - Phone:619-543-7636
Mailing Address - Fax:619-543-7898
Practice Address - Street 1:200 W ARBOR DR
Practice Address - Street 2:MAIL CODE: 0834
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-9000
Practice Address - Country:US
Practice Address - Phone:619-543-7636
Practice Address - Fax:619-543-7898
Is Sole Proprietor?:No
Enumeration Date:2010-07-14
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TXQ84592085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX358794102OtherCSHCN
TX358794101Medicaid
TX358794101Medicaid