Provider Demographics
NPI:1689670861
Name:DAVIS, MICHAEL (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1337
Mailing Address - Street 2:GALLUP INDIAN MEDICAL CENTER DEPARTMENT 18
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87305-1337
Mailing Address - Country:US
Mailing Address - Phone:505-722-1331
Mailing Address - Fax:505-722-1747
Practice Address - Street 1:516 NIZHONI BLVD
Practice Address - Street 2:DEPARTMENT 18
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5748
Practice Address - Country:US
Practice Address - Phone:505-722-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2154152W00000X
NM516152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8HZ342Medicare ID - Type Unspecified
U85260Medicare UPIN