Provider Demographics
NPI:1275838690
Name:DAVIS DEVELOPMENTAL PEDIATRICS GROUP, INC
Entity Type:Organization
Organization Name:DAVIS DEVELOPMENTAL PEDIATRICS GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN, PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:T
Authorized Official - Last Name:NOWICKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:530-220-3039
Mailing Address - Street 1:2747 GANGES PL
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2921
Mailing Address - Country:US
Mailing Address - Phone:530-758-3374
Mailing Address - Fax:530-758-3374
Practice Address - Street 1:1321 COLLEGE ST
Practice Address - Street 2:SUITE E
Practice Address - City:WOODLAND
Practice Address - State:CA
Practice Address - Zip Code:95695-4706
Practice Address - Country:US
Practice Address - Phone:530-758-3374
Practice Address - Fax:530-746-0657
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-15
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0789492080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH93901Medicare UPIN