MEDICARE: KELLEY MICHELLE DAVIS D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	L8319	TX

General Provider Information

NPI Number	:	1609833771
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLEY MICHELLE DAVIS D.O.

Provider Business Mailing Address
First Line	:	1251A E RED BIRD LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-2008
Country	:	US
Telephone Number	:	214-374-0827
Fax Number	:	214-374-0927

Provider Business Practice Location Address
First Line	:	1251A E RED BIRD LN
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75241-2008
Country	:	US
Telephone Number	:	214-374-0827
Fax Number	:	214-374-0927

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2006
Last Update Date	:	11/02/2007

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