Provider Demographics
NPI:1659525715
Name:DAVIDOVSKY, GRIGORY
Entity Type:Individual
Prefix:
First Name:GRIGORY
Middle Name:
Last Name:DAVIDOVSKY
Suffix:
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 1:1448 N SIERRA BONITA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046-4112
Mailing Address - Country:US
Mailing Address - Phone:323-850-0578
Mailing Address - Fax:323-297-5151
Practice Address - Street 1:1448 N SIERRA BONITA AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90046-4112
Practice Address - Country:US
Practice Address - Phone:323-850-0578
Practice Address - Fax:323-297-5151
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-14
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0811500001Medicare NSC