Provider Demographics
NPI:1205039872
Name:MAHONEY, DAVID BLAIR (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BLAIR
Last Name:MAHONEY
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 1:235 S PALISADE DR
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-5948
Mailing Address - Country:US
Mailing Address - Phone:805-739-3561
Mailing Address - Fax:805-739-3560
Practice Address - Street 1:235 S PALISADE DR
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5948
Practice Address - Country:US
Practice Address - Phone:805-739-3561
Practice Address - Fax:805-739-3560
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2024-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC35184207Q00000X
CAC194569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC351844Medicaid