Provider Demographics
NPI:1194869529
Name:DAVIS, MICHAEL JEROME JR (DPT)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JEROME
Last Name:DAVIS
Suffix:JR
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4967 SHADY GROVE RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23059-6006
Mailing Address - Country:US
Mailing Address - Phone:703-973-4967
Mailing Address - Fax:
Practice Address - Street 1:2208 IROQUOIS LN
Practice Address - Street 2:
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22043-2506
Practice Address - Country:US
Practice Address - Phone:703-973-4967
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-18
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305204165225100000X
PAPT016539225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist