Provider Demographics
NPI:1780642306
Name:LUNDQUIST, DAVIN R (MD)
Entity Type:Individual
Prefix:
First Name:DAVIN
Middle Name:R
Last Name:LUNDQUIST
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5051 VERDUGO WAY STE 100
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8681
Practice Address - Country:US
Practice Address - Phone:805-384-8071
Practice Address - Fax:805-987-1927
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA79975207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03505561Medicaid
MS080004165Medicare ID - Type UnspecifiedINDIVIDUAL PROVIDER NUMBE
MSC03404Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
MS03505561Medicaid