Provider Demographics
NPI:1134232192
Name:TIMOTHY T DAVIS M.D. A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:TIMOTHY T DAVIS M.D. A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:T
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-828-7757
Mailing Address - Street 1:1301 20TH ST
Mailing Address - Street 2:400
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2050
Mailing Address - Country:US
Mailing Address - Phone:310-828-7757
Mailing Address - Fax:
Practice Address - Street 1:122 SHELDON ST
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3915
Practice Address - Country:US
Practice Address - Phone:310-322-4278
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA637422081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA63742Medicare ID - Type Unspecified