Healthcare Provider Details

I. General information

NPI: 1164459178
Provider Name (Legal Business Name): MARK MEHRDAD DAVIDSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8631 W 3RD ST 1135-E
LOS ANGELES CA
90048-5901
US

IV. Provider business mailing address

PO BOX 7487
BEVERLY HILLS CA
90212-7487
US

V. Phone/Fax

Practice location:
  • Phone: 310-855-0222
  • Fax: 310-652-1905
Mailing address:
  • Phone: 310-855-0222
  • Fax: 310-652-1905

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA67586
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberA67586
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RI0008X
TaxonomyHepatology Physician
License NumberA67586
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: