Provider Demographics
NPI:1336123348
Name:DAFOE, DONALD (MD)
Entity Type:Individual
Prefix:DR
First Name:DONALD
Middle Name:
Last Name:DAFOE
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 512717
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0717
Mailing Address - Country:US
Mailing Address - Phone:310-423-4621
Mailing Address - Fax:310-423-3864
Practice Address - Street 1:8700 BEVERLY BLVD.
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-1865
Practice Address - Country:US
Practice Address - Phone:310-423-4621
Practice Address - Fax:310-423-3864
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG72690208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA76565Medicare UPIN