Provider Demographics
NPI:1720288426
Name:JONATHAN W.R. DAVIES
Entity Type:Organization
Organization Name:JONATHAN W.R. DAVIES
Other - Org Name:LAKE COUNTY OBSTETRICS AND GYNECOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:W R
Authorized Official - Last Name:DAVIES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-263-9036
Mailing Address - Street 1:5106 HILL RD E
Mailing Address - Street 2:
Mailing Address - City:LAKEPORT
Mailing Address - State:CA
Mailing Address - Zip Code:95453-6300
Mailing Address - Country:US
Mailing Address - Phone:707-263-9036
Mailing Address - Fax:707-263-9039
Practice Address - Street 1:5106 HILL RD E
Practice Address - Street 2:
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-6300
Practice Address - Country:US
Practice Address - Phone:707-263-9036
Practice Address - Fax:707-263-9039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-20
Last Update Date:2013-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA72280207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A722800Medicaid
CA00A722801Medicare PIN