Basic Information
| Provider Information | |||||||||
| NPI: | 1477622934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6920 POINTE INVERNESS WAY STE 200 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468047934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604793514 | ||||||||
| FaxNumber: | 2604793520 | ||||||||
| Practice Location | |||||||||
| Address1: | 7900 W JEFFERSON BLVD STE 306 | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468044128 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604583610 | ||||||||
| FaxNumber: | 2604583611 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 04/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208200000X | 26620 | AL | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208200000X | P1857 | TX | N | Allopathic & Osteopathic Physicians | Plastic Surgery | 208200000X | 01053296A | IN | Y | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 009941892 | 05 | AL | MEDICAID | 051540216 | 01 | AL | BCBS | OTHER | 009941891 | 05 | AL | MEDICAID | 009942208 | 05 | AL | MEDICAID | 051540217 | 01 | AL | BCBS | OTHER | 051540215 | 01 | AL | BCBS | OTHER |