Provider Demographics
NPI:1891945234
Name:MICHAEL L DAVIS M.D., P.A.
Entity Type:Organization
Organization Name:MICHAEL L DAVIS M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D./PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-630-9755
Mailing Address - Street 1:2100 HIGHWAY 61 N
Mailing Address - Street 2:
Mailing Address - City:VICKSBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39183-8211
Mailing Address - Country:US
Mailing Address - Phone:601-630-9755
Mailing Address - Fax:601-630-9120
Practice Address - Street 1:2100 HIGHWAY 61 N
Practice Address - Street 2:
Practice Address - City:VICKSBURG
Practice Address - State:MS
Practice Address - Zip Code:39183-8211
Practice Address - Country:US
Practice Address - Phone:601-630-9755
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-23
Last Update Date:2009-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08327207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1319422Medicaid
MS09455302Medicaid
MS09455302Medicaid