Provider Demographics
NPI:1558307173
Name:PACKARD, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:PACKARD
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 1:26800 CROWN VALLEY PKWY STE 305
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8017
Mailing Address - Country:US
Mailing Address - Phone:949-364-6000
Mailing Address - Fax:949-364-3213
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 250
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-364-0644
Practice Address - Fax:949-364-1520
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA73876207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0100620Medicaid
CAGV944ZMedicare PIN
CAGR0100620Medicaid
ZZZ016292Medicare ID - Type Unspecified