Provider Demographics
NPI:1558778043
Name:MATTOX, DANIEL THOMAS
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:THOMAS
Last Name:MATTOX
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26265 MONTICELLO WAY
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4094
Mailing Address - Country:US
Mailing Address - Phone:626-848-6670
Mailing Address - Fax:
Practice Address - Street 1:2305 HISTORIC DECATUR RD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6071
Practice Address - Country:US
Practice Address - Phone:619-613-2791
Practice Address - Fax:619-415-8415
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
HIAPRN-4066363LP0808X
CA95023069363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator