Healthcare Provider Details

I. General information

NPI: 1134232192
Provider Name (Legal Business Name): TIMOTHY T DAVIS M.D. A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 12/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

122 SHELDON ST
EL SEGUNDO CA
90245-3915
US

IV. Provider business mailing address

1301 20TH ST 400
SANTA MONICA CA
90404-2050
US

V. Phone/Fax

Practice location:
  • Phone: 310-322-4278
  • Fax:
Mailing address:
  • Phone: 310-828-7757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA63742
License Number StateCA

VIII. Authorized Official

Name: TIMOTHY T DAVIS
Title or Position: OWNER
Credential: M.D.
Phone: 310-828-7757