Provider Demographics
NPI:1124064225
Name:DAVIS, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5733
Practice Address - Street 1:12010 SHELBYVILLE RD
Practice Address - Street 2:SUITE 400
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40243-1054
Practice Address - Country:US
Practice Address - Phone:502-897-9191
Practice Address - Fax:502-897-7626
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KY26497207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000500017OtherANTHEM
KY6426497100Medicaid
KY00162022Medicare PIN
E74680Medicare UPIN
KY000000500017OtherANTHEM