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Jerome Gary Davidson

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NPI Number Detailed Information

Provider Information:

Name: Jerome Gary Davidson
Gender: M
Provider License Number If Given: A22489

NPI Information:

NPI: 1114926490
Entity Type
(Individual or Organization):
1-ind
Enumeration Date: 7/19/2005

Last Update Date: 6/8/2011

Provider Business Mailing Address:

Address: PO BOX 11307
San Bernardino, CA 92423
Phone Number: 8187002336
Fax Number: 8187002337

Provider Business Practice Location Address:

Address: 18300 ROSCOE BLVD
Northridge, CA 91325
Phone Number: 8187002336
Fax Number: 8187002337

Provider Taxonomy:

Primary: 207RH0003X
Secondary (if any):
State: CA

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