Provider Demographics
NPI:1033307277
Name:SUSAN M. DANEK MD A PROFESSIONAL MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SUSAN M. DANEK MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:DANEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-301-7191
Mailing Address - Street 1:29798 HAUN RD
Mailing Address - Street 2:SUITE 302
Mailing Address - City:SUN CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92586-6541
Mailing Address - Country:US
Mailing Address - Phone:951-301-7191
Mailing Address - Fax:951-301-4160
Practice Address - Street 1:29798 HAUN RD
Practice Address - Street 2:SUITE 302
Practice Address - City:SUN CITY
Practice Address - State:CA
Practice Address - Zip Code:92586-6541
Practice Address - Country:US
Practice Address - Phone:951-301-7191
Practice Address - Fax:951-301-4160
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG080713261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG80713Medicare UPIN