Provider Demographics
NPI:1972007425
Name:TREVIZO, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:TREVIZO
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 1:500B JEFFERSON BLVD STE 180
Mailing Address - Street 2:
Mailing Address - City:W SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95605-2307
Mailing Address - Country:US
Mailing Address - Phone:916-403-2900
Mailing Address - Fax:916-734-5636
Practice Address - Street 1:500B JEFFERSON BLVD STE 180
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95605-2394
Practice Address - Country:US
Practice Address - Phone:916-403-2900
Practice Address - Fax:530-204-5248
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAA163932207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program