Provider Demographics
NPI:1376591594
Name:CASSIDY, DAVID LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:LEE
Last Name:CASSIDY
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 1:18944 MOUNT CIMARRON ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-7313
Mailing Address - Country:US
Mailing Address - Phone:714-968-7706
Mailing Address - Fax:
Practice Address - Street 1:18944 MOUNT CIMARRON ST
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-7313
Practice Address - Country:US
Practice Address - Phone:714-968-7706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC28354174400000X, 2085R0202X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
No2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C283540OtherBLUE SHIELD
CA00C283540Medicaid
CA00C283540221OtherCALOPTIMA
CA00C283540Medicaid
CAWC28354FMedicare PIN