Provider Demographics
NPI:1508981150
Name:DANIEL, ROLLIN K (MD, FACS)
Entity Type:Individual
Prefix:
First Name:ROLLIN
Middle Name:K
Last Name:DANIEL
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 AVOCADO AVE
Mailing Address - Street 2:SUITE 308
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7721
Mailing Address - Country:US
Mailing Address - Phone:949-721-0494
Mailing Address - Fax:949-721-4138
Practice Address - Street 1:1441 AVOCADO AVE
Practice Address - Street 2:SUITE 308
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7721
Practice Address - Country:US
Practice Address - Phone:949-721-0494
Practice Address - Fax:949-721-4138
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46174174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist