Provider Demographics
NPI:1669823662
Name:DAVIS, JUSTIN LANE (DO)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LANE
Last Name:DAVIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4140 W 190TH ST STE 306
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-8780
Mailing Address - Fax:
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-8780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK6152207P00000X
CA20A18362207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine