Provider Demographics
NPI:1154430783
Name:DAVIDSON, MAYER B (MD)
Entity type:Individual
Prefix:
First Name:MAYER
Middle Name:B
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3616 OCEAN VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-3114
Mailing Address - Country:US
Mailing Address - Phone:323-357-3439
Mailing Address - Fax:
Practice Address - Street 1:1760 EAST 120TH STREET
Practice Address - Street 2:MARTIN LUTHER KING OUTPATIENT CENTER.
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3019
Practice Address - Country:US
Practice Address - Phone:323-357-3439
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG18264207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA40310Medicare UPIN