Provider Demographics
NPI:1902108293
Name:WEST VALLEY HEMATOLOGY ONCOLOGY MEDICAL GROUP
Entity Type:Organization
Organization Name:WEST VALLEY HEMATOLOGY ONCOLOGY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:818-700-2336
Mailing Address - Street 1:PO BOX 11307
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-1307
Mailing Address - Country:US
Mailing Address - Phone:888-344-9111
Mailing Address - Fax:909-335-7130
Practice Address - Street 1:18300 ROSCOE BLVD
Practice Address - Street 2:LEAVEY CANCER CENTER
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91325-4105
Practice Address - Country:US
Practice Address - Phone:818-700-2336
Practice Address - Fax:818-700-2337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-19
Last Update Date:2013-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902108293Medicaid
CA1902108293Medicaid