Provider Demographics
NPI:1619236205
Name:DAVID MEDICAL ENTERPRISES
Entity type:Organization
Organization Name:DAVID MEDICAL ENTERPRISES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, DIRECT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARC
Authorized Official - Middle Name:FREDERIQUE
Authorized Official - Last Name:DAVID
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-403-5382
Mailing Address - Street 1:PO BOX 23955
Mailing Address - Street 2:MARC FREDERIQUE DAVID
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31403-3995
Mailing Address - Country:US
Mailing Address - Phone:912-354-4239
Mailing Address - Fax:
Practice Address - Street 1:3840 WATERS AVENUE
Practice Address - Street 2:I CARE FAMILY MEDICINE CLINIC
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31404-6264
Practice Address - Country:US
Practice Address - Phone:912-354-4239
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAVID MEDICAL ENTERPRISES
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.047838207Q00000X
207Q00000X
GA26091207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121635AMedicaid