Provider Demographics
NPI:1528004744
Name:DAVIS, MATTHEW L (MD)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:L
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2500 NILES ROAD
Mailing Address - Street 2:SUITE #7
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:48085
Mailing Address - Country:US
Mailing Address - Phone:269-982-7844
Mailing Address - Fax:269-982-1783
Practice Address - Street 1:2500 NILES ROAD
Practice Address - Street 2:SUITE #7
Practice Address - City:ST. JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-982-7844
Practice Address - Fax:269-982-1783
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2011-01-25
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI43010847622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4301084762OtherSTATE LISCENSE
186520Medicare ID - Type Unspecified
G14724Medicare UPIN