Provider Demographics
NPI:1407019391
Name:DEBOTTIS, DANIEL PATRICK (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:PATRICK
Last Name:DEBOTTIS
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 1:280 S MAIN ST
Mailing Address - Street 2:STE 200
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3852
Mailing Address - Country:US
Mailing Address - Phone:714-634-4567
Mailing Address - Fax:
Practice Address - Street 1:280 S MAIN ST
Practice Address - Street 2:STE 200
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3852
Practice Address - Country:US
Practice Address - Phone:714-634-4567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126199207X00000X, 207X00000X
RI13855207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB239349OtherMEDICARE PTAN