Provider Demographics
NPI:1922073998
Name:DAVIDSON, JERRY A (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:A
Last Name:DAVIDSON
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2876 SYCAMORE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1550
Mailing Address - Country:US
Mailing Address - Phone:805-527-6424
Mailing Address - Fax:805-522-0115
Practice Address - Street 1:2876 SYCAMORE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1550
Practice Address - Country:US
Practice Address - Phone:805-527-6424
Practice Address - Fax:805-522-0115
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2011-04-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG33458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G334580Medicaid
CAA45557Medicare UPIN
CA00G334580Medicaid