Provider Demographics
NPI:1477622934
Name:DAVIS, MICHAEL ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:ROBERT
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-479-3514
Mailing Address - Fax:260-479-3520
Practice Address - Street 1:7900 W JEFFERSON BLVD STE 306
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4128
Practice Address - Country:US
Practice Address - Phone:260-458-3610
Practice Address - Fax:260-458-3611
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26620208200000X
TXP1857208200000X
IN01053296A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009941892Medicaid
AL051540216OtherBCBS
AL009941891Medicaid
AL009942208Medicaid
AL051540217OtherBCBS
AL051540215OtherBCBS
AL051540216OtherBCBS