Provider Demographics
NPI:1386054039
Name:DAVIS, MITCHELL
Entity type:Individual
Prefix:MR
First Name:MITCHELL
Middle Name:
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111312 VILLAGE RD
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-1385
Mailing Address - Country:US
Mailing Address - Phone:952-221-2237
Mailing Address - Fax:
Practice Address - Street 1:111312 VILLAGE RD
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-1385
Practice Address - Country:US
Practice Address - Phone:650-321-9999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-04
Last Update Date:2014-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAQ307148741310242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist