Healthcare Provider Details

I. General information

NPI: 1487646212
Provider Name (Legal Business Name): DAVID L MCANINCH III MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2005
Last Update Date: 08/18/2021
Certification Date: 08/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 E OCEAN AVE
LOMPOC CA
93436-7092
US

IV. Provider business mailing address

PO BOX 7462
ORANGE CA
92863-7462
US

V. Phone/Fax

Practice location:
  • Phone: 805-737-3375
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG42124
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00G421240
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer
# 2
Identifier360001893
Identifier TypeOTHER
Identifier State
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: