Active NPI
Michael Davidson, PA-C
- Medical Physician Assistant
- Fort Polk, LA
National Provider Identifier
1255480018
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Medical Physician Assistant
- License
- 1041591
- Practice address
- 1585 3Rd St
Fort Polk, LA 71459-5102 - Phone
- (337) 531-3517
- NPI assigned
- Jan 10, 2007
- Last updated
- May 12, 2021
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Medical Physician Assistant | 363AM0700X | 1041591 | NU | Primary |
Addresses
Primary practice location
1585 3Rd St
Fort Polk, LA 71459-5102
Mailing address
1776 Polk St Apt 1917
Hollywood, FL 33020-4776
Phone (210) 819-9648
Other practice location 1
Southcom Health Clinic
9301 NW 33rd Street
Doral, FL 33171
Phone (305) 437-1720
Other practice location 2
3551 Roger Brooke Dr
Fort Sam Houston, TX 78234-4504
Phone (210) 916-4141
Other practice location 3
CMR 411 Box 2211
Apo, AE 09112
DE
Phone 011499662702050
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Enrolled
- Credentials
- Physician Assistant
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1168387200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1620777600000",
"number": "1255480018",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1776 POLK ST APT 1917",
"city": "HOLLYWOOD",
"state": "FL",
"postal_code": "330204776",
"telephone_number": "210-819-9648"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1585 3RD ST",
"city": "FORT POLK",
"state": "LA",
"postal_code": "714595102",
"telephone_number": "337-531-3517"
}
],
"practiceLocations": [
{
"address_1": "Southcom Health Clinic",
"address_2": "9301 NW 33rd Street",
"address_purpose": "LOCATION",
"city": "Doral",
"state": "FL",
"postal_code": "33171",
"country_code": "US",
"telephone_number": "305-437-1720",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "3551 Roger Brooke Dr",
"address_purpose": "LOCATION",
"city": "Fort Sam Houston",
"state": "TX",
"postal_code": "782344504",
"country_code": "US",
"telephone_number": "210-916-4141",
"country_name": "United States",
"address_type": "DOM"
},
{
"address_1": "CMR 411 BOX 2211",
"address_purpose": "LOCATION",
"city": "APO",
"state": "AE",
"postal_code": "09112",
"country_code": "DE",
"telephone_number": "011499662702050",
"country_name": "Germany",
"address_type": "FGN"
}
],
"basic": {
"last_name": "DAVIDSON",
"first_name": "MICHAEL",
"credential": "PA-C",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2007-01-10",
"last_updated": "2021-05-12",
"certification_date": "2021-04-18",
"status": "A"
},
"taxonomies": [
{
"code": "363AM0700X",
"taxonomy_group": "",
"desc": "Physician Assistant, Medical",
"state": "NU",
"license": "1041591",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fort Polk, LA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 12, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.