Provider Demographics
NPI:1093766925
Name:TREJO, DANIEL A (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:TREJO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1060
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:LA
Mailing Address - Zip Code:71221-1060
Mailing Address - Country:US
Mailing Address - Phone:318-283-3920
Mailing Address - Fax:
Practice Address - Street 1:430 S VINE ST
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:LA
Practice Address - Zip Code:71220-4514
Practice Address - Country:US
Practice Address - Phone:318-283-3970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14979R207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAH81815Medicare UPIN