Basic Information
| Provider Information | |||||||||
| NPI: | 1417931387 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | UNIVERSITY OF CALIFORNIA, DAVIS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 5709 THAMES WAY | ||||||||
| Address2: | |||||||||
| City: | CARMICHAEL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956085556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9164879317 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4150 V ST | ||||||||
| Address2: | PSSB G500 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167348695 | ||||||||
| FaxNumber: | 9167347766 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2005 | ||||||||
| LastUpdateDate: | 06/20/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ASMUTH | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT PROFESSOR OF CLINICAL MED | ||||||||
| AuthorizedOfficialTelephone: | 9167348695 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 00G865750 | CA | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00G865750 | 01 | CA | MEDI-CAL | OTHER |