Provider Demographics
NPI:1629061726
Name:DAVIS, MICHAEL PRENTICE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PRENTICE
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 1:1514 JEFFERSON HWY
Mailing Address - Street 2:HOSPITALIST GROVE
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-349-1656
Mailing Address - Fax:504-349-1933
Practice Address - Street 1:2005 VETERANS MEMORIAL BLVD FL 6
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70002-6320
Practice Address - Country:US
Practice Address - Phone:504-836-9820
Practice Address - Fax:504-846-9608
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA025236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1140368Medicaid
MS03901261Medicaid
MS03901261Medicaid