Provider Demographics
NPI:1639109713
Name:VIA VERDE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:VIA VERDE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:E
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:909-592-9778
Mailing Address - Street 1:1125 VIA VERDE
Mailing Address - Street 2:
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-4400
Mailing Address - Country:US
Mailing Address - Phone:909-592-9778
Mailing Address - Fax:909-599-6126
Practice Address - Street 1:1125 VIA VERDE
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-4400
Practice Address - Country:US
Practice Address - Phone:909-592-9778
Practice Address - Fax:909-599-6126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5217207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15055Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER