Provider Demographics
NPI:1609949254
Name:DAVIS, MIRYAM M
Entity Type:Individual
Prefix:
First Name:MIRYAM
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7012 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-4752
Mailing Address - Country:US
Mailing Address - Phone:301-229-6250
Mailing Address - Fax:301-320-3590
Practice Address - Street 1:106 IRVING ST NW
Practice Address - Street 2:#206
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20010-2927
Practice Address - Country:US
Practice Address - Phone:202-291-7300
Practice Address - Fax:202-726-6031
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD4085204D00000X, 2084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC022868200Medicaid
DCC88585Medicare UPIN
DC022868200Medicaid