Basic Information
| Provider Information | |||||||||
| NPI: | 1770502601 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | MITCHELL | ||||||||
| MiddleName: | N. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5431 N UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330674639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543442522 | ||||||||
| FaxNumber: | 9543449189 | ||||||||
| Practice Location | |||||||||
| Address1: | 1447 MEDICAL PARK BLVD | ||||||||
| Address2: | SUITE 205 | ||||||||
| City: | WELLINGTON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334143164 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617982425 | ||||||||
| FaxNumber: | 5617986356 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 10/10/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | OS6182 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 054410800 | 05 | FL | MEDICAID |