Basic Information
| Provider Information | |||||||||
| NPI: | 1154300978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIS | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1125 VIA VERDE | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917734400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095929778 | ||||||||
| FaxNumber: | 9095996126 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 VIA VERDE | ||||||||
| Address2: | |||||||||
| City: | SAN DIMAS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917734400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095929778 | ||||||||
| FaxNumber: | 9095996126 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 20A5217 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00AX52170 | 05 | CA | MEDICAID |