Provider Demographics
NPI:1437320785
Name:DAVIS, MICHAEL J (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
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 1:301 W HUNTINGTON DR
Mailing Address - Street 2:STE 107
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91007-3462
Mailing Address - Country:US
Mailing Address - Phone:626-574-0020
Mailing Address - Fax:626-574-7188
Practice Address - Street 1:301 W HUNTINGTON DR
Practice Address - Street 2:STE 107
Practice Address - City:ARCADIA
Practice Address - State:CA
Practice Address - Zip Code:91007-3462
Practice Address - Country:US
Practice Address - Phone:626-574-0020
Practice Address - Fax:626-574-7188
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA111866207W00000X, 207WX0107X
IL036120010207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036120010 1Medicaid
ILK52720Medicare PIN
INM400019452Medicare PIN