Provider Demographics
NPI:1053470468
Name:SOUTH, DAVID ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ALLEN
Last Name:SOUTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 GREEN VALLEY ROAD
Mailing Address - Street 2:
Mailing Address - City:FREEDOM
Mailing Address - State:CA
Mailing Address - Zip Code:95019
Mailing Address - Country:US
Mailing Address - Phone:831-728-2005
Mailing Address - Fax:831-728-3310
Practice Address - Street 1:204 GREEN VALLEY ROAD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019
Practice Address - Country:US
Practice Address - Phone:831-728-2005
Practice Address - Fax:831-728-3310
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2009-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30108207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G301080Medicaid
ZZZ29084ZMedicare ID - Type Unspecified
070007468Medicare ID - Type UnspecifiedRAILROAD
CA00G301080Medicaid