Provider Demographics
NPI:1407552706
Name:DAVIS, DOUGLAS DEAN II
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DEAN
Last Name:DAVIS
Suffix:II
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 1:16536 BALLINGER ST
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-1806
Mailing Address - Country:US
Mailing Address - Phone:818-293-9596
Mailing Address - Fax:
Practice Address - Street 1:16650 SHERMAN WAY
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3782
Practice Address - Country:US
Practice Address - Phone:818-901-4836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-07
Last Update Date:2023-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker