Provider Demographics
NPI:1689670861
Name:DAVIS, MICHAEL (OD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:861 S 700 E
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2963
Mailing Address - Country:US
Mailing Address - Phone:505-409-8664
Mailing Address - Fax:
Practice Address - Street 1:HWY 371 JUNCTION HWY 57 RT 9
Practice Address - Street 2:
Practice Address - City:CROWNPOINT
Practice Address - State:NM
Practice Address - Zip Code:87313
Practice Address - Country:US
Practice Address - Phone:505-786-5291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2154152W00000X
UT12403819-9934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
8HZ342Medicare ID - Type Unspecified
U85260Medicare UPIN