1790938306 NPI number — DAVIN WILSON CHARK M.D.

Table of content: DAVIN WILSON CHARK M.D. (NPI 1790938306)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790938306 NPI number — DAVIN WILSON CHARK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CHARK
Provider First Name:
DAVIN
Provider Middle Name:
WILSON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790938306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12151 BAYPORT ST
Provider Second Line Business Mailing Address:
APT.# 10-208
Provider Business Mailing Address City Name:
GARDEN GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92840-4471
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-243-7926
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 THE CITY DR S
Provider Second Line Business Practice Location Address:
BLDG 56, STE 500
Provider Business Practice Location Address City Name:
ORANGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92868-3201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-456-5753
Provider Business Practice Location Address Fax Number:
714-456-5747
Provider Enumeration Date:
10/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)