Provider Demographics
NPI:1477013175
Name:DAVID, JILL LISA (DO)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:LISA
Last Name:DAVID
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 FLORIDA AVE
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4404
Mailing Address - Country:US
Mailing Address - Phone:209-576-3525
Mailing Address - Fax:209-729-4008
Practice Address - Street 1:1441 FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4404
Practice Address - Country:US
Practice Address - Phone:209-576-3525
Practice Address - Fax:209-729-4008
Is Sole Proprietor?:No
Enumeration Date:2019-03-20
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A22900207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine