Provider Demographics
NPI:1689084063
Name:MESA, DAVID JR
Entity Type:Individual
Prefix:MR
First Name:DAVID
Middle Name:
Last Name:MESA
Suffix:JR
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 1:1104 S GARFIELD AVE STE A
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-7803
Mailing Address - Country:US
Mailing Address - Phone:626-872-2899
Mailing Address - Fax:626-872-2892
Practice Address - Street 1:1104 S GARFIELD AVE STE A
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-7803
Practice Address - Country:US
Practice Address - Phone:626-872-2899
Practice Address - Fax:626-872-2892
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA05D2065387246RM2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RM2200XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyMedical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA05D2065387OtherSTATE LABORATORY LICENSE