Provider Demographics
NPI:1386756930
Name:PAMELA D. DAVIS, M.D., INC.
Entity type:Organization
Organization Name:PAMELA D. DAVIS, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:D
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-413-3541
Mailing Address - Street 1:133 N. PRAIRIE AVE.
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4878
Mailing Address - Country:US
Mailing Address - Phone:310-419-0900
Mailing Address - Fax:310-622-8776
Practice Address - Street 1:133 N. PRAIRIE AVE.
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4878
Practice Address - Country:US
Practice Address - Phone:310-419-0900
Practice Address - Fax:310-622-8776
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PAMELA D. DAVIS, M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-31
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46258207L00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G462580Medicaid
CA00G462580Medicaid