Provider Demographics
NPI:1073977534
Name:DANIELS, MICHEAL T
Entity Type:Individual
Prefix:MR
First Name:MICHEAL
Middle Name:T
Last Name:DANIELS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3265 ADAMS AVE APT 31
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1649
Mailing Address - Country:US
Mailing Address - Phone:760-508-9540
Mailing Address - Fax:
Practice Address - Street 1:3265 ADAMS AVE APT 31
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1649
Practice Address - Country:US
Practice Address - Phone:760-508-9540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00796237174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
228226OtherOPEN
CA228226Medicaid
CA228226Medicaid
CA228226Medicare PIN
228226OtherOPEN
2282261346Medicare NSC