Healthcare Provider Details

I. General information

NPI: 1639139751
Provider Name (Legal Business Name): MICHAEL F. DAVIS DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 10/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E BROWN ST POCONO KIDS PEDIATRICS
E STROUDSBURG PA
18301-3006
US

IV. Provider business mailing address

61 MEMORIAL MEDICAL PKWY SUITE 3811
PALM COAST FL
32164-5981
US

V. Phone/Fax

Practice location:
  • Phone: 570-476-3585
  • Fax: 570-421-9014
Mailing address:
  • Phone: 386-986-4919
  • Fax: 386-986-4922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberOS9939
License Number StateFL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier280132900
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: