Provider Demographics
NPI:1487653531
Name:DAVID, DWIGHT A (MD)
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:A
Last Name:DAVID
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 1:15111 WHITTIER BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90603-2136
Mailing Address - Country:US
Mailing Address - Phone:562-945-6440
Mailing Address - Fax:562-945-9121
Practice Address - Street 1:15111 WHITTIER BLVD
Practice Address - Street 2:STE 102
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90603-2136
Practice Address - Country:US
Practice Address - Phone:562-945-6440
Practice Address - Fax:562-945-9121
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA40764208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A407640OtherBLUE SHIELD
CAA40764OtherBCBS
CAB010OtherCHAMPUS
CA00A407640Medicaid
CA110232328OtherMEDICARE RAIL ROAD
CAB010OtherCHAMPUS
CAWA40764HMedicare PIN