Basic Information
Provider Information | |||||||||
NPI: | 1386639037 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DAVIS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.O. ANESTHESIOLOGIS | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 509 N BROAD ST | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | NJ | ||||||||
PostalCode: | 080961617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8568450100 | ||||||||
FaxNumber: | 8568487023 | ||||||||
Practice Location | |||||||||
Address1: | 509 N BROAD ST | ||||||||
Address2: |   | ||||||||
City: | WOODBURY | ||||||||
State: | NJ | ||||||||
PostalCode: | 080961617 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8568450100 | ||||||||
FaxNumber: | 8568487023 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/19/2005 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X |   | NJ | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 7522100 | 05 | NJ |   | MEDICAID | D07202200 | 01 | NJ | CDS | OTHER | BD5416789 | 01 |   | DEA | OTHER | 25MB61648 | 01 | NJ | MEDICAL LICENSE | OTHER |