Provider Demographics
NPI:1194840231
Name:DAVIS, CHARLES R
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:R
Last Name:DAVIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 PRECISION PARK LN
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-1345
Mailing Address - Country:US
Mailing Address - Phone:619-662-4100
Mailing Address - Fax:
Practice Address - Street 1:4004 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2007
Practice Address - Country:US
Practice Address - Phone:303-579-9268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO21195207Q00000X
CAG41219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01211952Medicaid
110519276OtherMEDICARE RAILROAD
COPENDINGMedicaid
CO01211952Medicaid