Provider Demographics
NPI:1386635803
Name:DAVIS, EDWARD LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:LEE
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 1:658 S WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4330
Mailing Address - Country:US
Mailing Address - Phone:626-335-7207
Mailing Address - Fax:
Practice Address - Street 1:658 S WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4330
Practice Address - Country:US
Practice Address - Phone:626-335-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG21363208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ72637ZMedicaid
A41263Medicare UPIN
CAZZZ72637ZMedicaid