Provider Demographics
NPI:1497813133
Name:DAILLAK, STEPHEN J (RPT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:J
Last Name:DAILLAK
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1191 CRESTON RD STE 115
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-3033
Mailing Address - Country:US
Mailing Address - Phone:805-239-3696
Mailing Address - Fax:805-239-3697
Practice Address - Street 1:1191 CRESTON RD STE 115
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-3033
Practice Address - Country:US
Practice Address - Phone:805-239-3696
Practice Address - Fax:805-239-3697
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27175208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT271750OtherBLUE SHIELD
CAZZZ06333ZOtherBLUE SHIELD GROUP
CAPT27175OtherBLUE CROSS
CAGPT001411Medicaid
CAPT27175OtherTRICARE
CAOPT271750OtherBLUE SHIELD