Provider Demographics
NPI:1467409250
Name:DASKALAKIS, THEODOROS MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:THEODOROS
Middle Name:MICHAEL
Last Name:DASKALAKIS
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 1:279 IMPERIAL HWY
Mailing Address - Street 2:SUITE 730
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-1041
Mailing Address - Country:US
Mailing Address - Phone:714-449-4841
Mailing Address - Fax:714-449-4956
Practice Address - Street 1:2141 N HARBOR BLVD
Practice Address - Street 2:SUITE 35000
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3827
Practice Address - Country:US
Practice Address - Phone:714-626-8630
Practice Address - Fax:714-626-8659
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-27
Last Update Date:2013-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90653174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACZ948ZMedicare PIN
CAI35747Medicare UPIN