Healthcare Provider Details

I. General information

NPI: 1689670861
Provider Name (Legal Business Name): MICHAEL DAVIS O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 04/08/2025
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

HWY 371 JUNCTION HWY 57 RT 9
CROWNPOINT NM
87313
US

IV. Provider business mailing address

861 S 700 E
PLEASANT GROVE UT
84062-2963
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-5291
  • Fax:
Mailing address:
  • Phone: 505-409-8664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2154
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number12403819-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: