MEDICARE: DR. MICHAEL W DAVIS PH.D.

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	103TC2200X	Clinical Child & Adolescent Psychologist	06-07P	AR
2	103TC0700X	Clinical Psychologist	06-07P	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5X989	OTHER	AR	BLUE CROSS BLUE SHIELD
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1588715486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MICHAEL W DAVIS PH.D.

Provider Business Mailing Address
First Line	:	2808 FOX MEADOW LANE
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72404-9346
Country	:	US
Telephone Number	:	870-335-2240
Fax Number	:	870-931-4457

Provider Business Practice Location Address
First Line	:	2808 FOX MEADOW LANE
Second Line	:
City	:	JONESBORO
State	:	AR
Zip	:	72404-9346
Country	:	US
Telephone Number	:	870-335-2240
Fax Number	:	870-931-4457

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

Provider Enumeration Date	:	01/16/2007
Last Update Date	:	05/10/2023

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