Provider Demographics
NPI:1952625543
Name:DAVIS, JEREMIAH C (MD)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:C
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 1:1885 BAY RD
Mailing Address - Street 2:
Mailing Address - City:EAST PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303-1312
Mailing Address - Country:US
Mailing Address - Phone:650-330-7400
Mailing Address - Fax:
Practice Address - Street 1:1885 BAY RD
Practice Address - Street 2:
Practice Address - City:EAST PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-1312
Practice Address - Country:US
Practice Address - Phone:650-330-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-25
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAML60157569208000000X
WAMD60342987208000000X
ORMD167331208000000X
CAC153312208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500671034Medicaid
ORR176758Medicare PIN