Provider Demographics
NPI:1023080686
Name:UNDERWOOD, DAVID J (MD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:J
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-0735
Mailing Address - Country:US
Mailing Address - Phone:626-915-5181
Mailing Address - Fax:626-331-2313
Practice Address - Street 1:414 E SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91723-1704
Practice Address - Country:US
Practice Address - Phone:626-915-5181
Practice Address - Fax:626-915-2313
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG754582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G754580Medicaid
CAWG75458EMedicare PIN
CAG07085Medicare UPIN
CAWG75458CMedicare PIN