Provider Demographics
NPI:1114926490
Name:DAVIDSON, JEROME GARY (MD)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:GARY
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11307
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-1307
Mailing Address - Country:US
Mailing Address - Phone:818-700-2336
Mailing Address - Fax:818-700-2337
Practice Address - Street 1:18300 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4105
Practice Address - Country:US
Practice Address - Phone:818-700-2336
Practice Address - Fax:818-700-2337
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22489207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA224890Medicaid
CA1114926490Medicaid
CA1902108293Medicaid
CA1114926490Medicaid
CAEU684ZMedicare PIN
CA1902108293Medicaid
CAA86526Medicare UPIN