Provider Demographics
NPI: | 1740206804 |
---|---|
Name: | SEWELL, DANIEL D (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | DANIEL |
Middle Name: | D |
Last Name: | SEWELL |
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 232410 |
Mailing Address - Street 2: | |
Mailing Address - City: | SAN DIEGO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92193-2410 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 200 W ARBOR DR |
Practice Address - Street 2: | MAIL CODE 8631 |
Practice Address - City: | SAN DIEGO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92103-9001 |
Practice Address - Country: | US |
Practice Address - Phone: | 619-543-3772 |
Practice Address - Fax: | 619-543-3648 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-14 |
Last Update Date: | 2020-06-01 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | A44259 | 2084P0800X, 2084P0805X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No | 2084P0805X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Geriatric Psychiatry |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CA | 00A442590 | Medicaid | |
CA | WA44259C | Medicare ID - Type Unspecified | |
CA | 00A442590 | Medicaid |