Basic Information
| Provider Information | |||||||||
| NPI: | 1417698952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | VINCENT | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1500 S DOUGLAS RD STE 230 | ||||||||
| Address2: | |||||||||
| City: | CORAL GABLES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331344108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8442441818 | ||||||||
| FaxNumber: | 8885120733 | ||||||||
| Practice Location | |||||||||
| Address1: | 1919 WEST ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | ANNAPOLIS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 214013954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106734965 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2022 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | BACB776896 | MD | Y |
ID Information
| ID | Type | State | Issuer | Description | BACB776896 | 01 | OTHER | OTHER |