Provider Demographics
NPI:1871500363
Name:MAC, DALJIT (MD)
Entity Type:Individual
Prefix:
First Name:DALJIT
Middle Name:
Last Name:MAC
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 1:5014 CHESEBRO RD.
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:AGOURA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91301-4232
Mailing Address - Country:US
Mailing Address - Phone:818-706-9300
Mailing Address - Fax:818-707-2672
Practice Address - Street 1:5014 CHESEBRO RD.
Practice Address - Street 2:2ND FLOOR
Practice Address - City:AGOURA HILLS
Practice Address - State:CA
Practice Address - Zip Code:91301-4232
Practice Address - Country:US
Practice Address - Phone:818-706-9300
Practice Address - Fax:818-707-2672
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC505022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C505020Medicaid
CA00C505020Medicaid
CAE20982Medicare UPIN
CAC50502Medicare PIN