Provider Demographics
NPI:1609804749
Name:DAVALOS, RICARDO (MD)
Entity Type:Individual
Prefix:DR
First Name:RICARDO
Middle Name:
Last Name:DAVALOS
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 1:150 AVENIDA CABRILLO
Mailing Address - Street 2:SUITE #A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92627
Mailing Address - Country:US
Mailing Address - Phone:949-369-6993
Mailing Address - Fax:949-369-6469
Practice Address - Street 1:150 AVENIDA CABRILLO
Practice Address - Street 2:SUITE #A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92627
Practice Address - Country:US
Practice Address - Phone:949-369-6993
Practice Address - Fax:949-369-6469
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65157207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA65157OtherSTATE LIC
CA00A651570Medicaid
CAH02901Medicare UPIN
CA00A651570Medicaid
CAWA65157AMedicare ID - Type Unspecified#1C