Provider Demographics
NPI:1457039760
Name:FRAZIER, DAVON L
Entity Type:Individual
Prefix:MR
First Name:DAVON
Middle Name:L
Last Name:FRAZIER
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:DAVON
Other - Middle Name:LAMAR
Other - Last Name:FRAZIER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:4735 COWELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-4461
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1949 5TH ST
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-4026
Practice Address - Country:US
Practice Address - Phone:530-753-2566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-06
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3313126171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator