Provider Demographics
NPI:1174694863
Name:GARRISON, DAVID JAMES (PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:JAMES
Last Name:GARRISON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6021 PACIFIC BLVD
Mailing Address - Street 2:SUITE 109
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-2953
Mailing Address - Country:US
Mailing Address - Phone:323-581-8200
Mailing Address - Fax:323-581-8222
Practice Address - Street 1:6021 PACIFIC BLVD
Practice Address - Street 2:SUITE 109
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-2953
Practice Address - Country:US
Practice Address - Phone:323-581-8200
Practice Address - Fax:323-581-8222
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12521174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA12521OtherMEDICAL LICENSE