Provider Demographics
NPI:1174528657
Name:DAVIDOVICH, RAFFAELE A (MD)
Entity type:Individual
Prefix:
First Name:RAFFAELE
Middle Name:A
Last Name:DAVIDOVICH
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 1:1236 N. MAGNOLIA AVE.
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801
Mailing Address - Country:US
Mailing Address - Phone:310-450-5095
Mailing Address - Fax:
Practice Address - Street 1:1236 N. MAGNOLIA AVE.
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2607
Practice Address - Country:US
Practice Address - Phone:714-995-1000
Practice Address - Fax:714-828-7926
Is Sole Proprietor?:No
Enumeration Date:2005-06-20
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA29865207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A298650OtherMEDI CAL #
CAB50116Medicare UPIN