Provider Demographics
NPI:1255440228
Name:DAVIS, ROBERT ALVIN (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALVIN
Last Name:DAVIS
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 1:3443 VILLA LN STE 10
Mailing Address - Street 2:
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94558-6417
Mailing Address - Country:US
Mailing Address - Phone:707-294-2203
Mailing Address - Fax:707-252-9012
Practice Address - Street 1:3443 VILLA LN STE 10
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558
Practice Address - Country:US
Practice Address - Phone:707-294-2203
Practice Address - Fax:707-252-9012
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG23265174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G232650Medicaid
CA05DO685765OtherCLIA
CA05DO685765OtherCLIA
CA00G232650Medicaid