Healthcare Provider Details

I. General information

NPI: 1114069705
Provider Name (Legal Business Name): CHARLES B. DAVIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

12765 CHAPARRO HILLS PL
SAN DIEGO CA
92130-2726
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-8910
  • Fax:
Mailing address:
  • Phone: 858-523-1326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License NumberG55828
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: