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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 |