Healthcare Provider Details

I. General information

NPI: 1174294938
Provider Name (Legal Business Name): DOUGLAS PETER DAVIDSON JR. PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2021
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date: 02/26/2022
Reactivation Date: 12/05/2022

III. Provider practice location address

50 ACACIA AVE
SAN RAFAEL CA
94901-2230
US

IV. Provider business mailing address

38332 MAPLE CT
MURRIETA CA
92562-3406
US

V. Phone/Fax

Practice location:
  • Phone: 951-816-8970
  • Fax:
Mailing address:
  • Phone: 951-816-8970
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number62399
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: