Provider Demographics
NPI:1104898576
Name:DAVIS, MICHELLE MIREILLE (MD)
Entity type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:MIREILLE
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:MIREILLE
Other - Last Name:MODINGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4224 HOUMA BLVD STE 350
Mailing Address - Street 2:
Mailing Address - City:METAIRIE
Mailing Address - State:LA
Mailing Address - Zip Code:70006-2980
Mailing Address - Country:US
Mailing Address - Phone:504-780-9112
Mailing Address - Fax:314-546-8784
Practice Address - Street 1:4224 HOUMA BLVD STE 350
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70006-2980
Practice Address - Country:US
Practice Address - Phone:504-780-9112
Practice Address - Fax:314-536-8784
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-01
Last Update Date:2019-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14461R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1123684Medicaid
LAH64378Medicare UPIN
LA4E333CP97Medicare PIN