Provider Demographics
NPI:1376530501
Name:DAVIS, THOMAS LLOYD (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:LLOYD
Last Name:DAVIS
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 1:4646 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-0102
Mailing Address - Country:US
Mailing Address - Phone:951-774-2800
Mailing Address - Fax:951-774-2846
Practice Address - Street 1:4646 BROCKTON AVE
Practice Address - Street 2:STE 201
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-0102
Practice Address - Country:US
Practice Address - Phone:951-774-2912
Practice Address - Fax:951-774-2915
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2011-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG30895207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A445B8Medicare ID - Type Unspecified