Provider Demographics
NPI:1265649651
Name:DAVIS, MICHAEL LEE (DO)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LEE
Last Name:DAVIS
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 1:1200 W TABOR RD BLDG SUITE275
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19141-3019
Mailing Address - Country:US
Mailing Address - Phone:215-456-8210
Mailing Address - Fax:215-456-1933
Practice Address - Street 1:1200 W TABOR RD BLDG SUITE275
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3019
Practice Address - Country:US
Practice Address - Phone:215-456-8210
Practice Address - Fax:215-456-1933
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA0T11593207R00000X
PAOS015556207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2C0453Medicaid
PA232290323OtherEMPLOYER IDENTIFICATION N