Provider Demographics
NPI:1689609687
Name:MEDWAY, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:MEDWAY
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 1:6572 CAMINO DEL REY
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-4511
Mailing Address - Country:US
Mailing Address - Phone:818-342-0215
Mailing Address - Fax:
Practice Address - Street 1:6572 CAMINO DEL REY
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-4511
Practice Address - Country:US
Practice Address - Phone:818-342-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79336207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G22983Medicare UPIN
WG79336CMedicare ID - Type Unspecified