Provider Demographics
NPI:1770649816
Name:HEADRICK, DANIEL J (MD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:J
Last Name:HEADRICK
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 6747
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92615-6747
Mailing Address - Country:US
Mailing Address - Phone:714-377-3749
Mailing Address - Fax:714-377-5642
Practice Address - Street 1:32301 CAMINO CAPISTRANO STE J
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-4512
Practice Address - Country:US
Practice Address - Phone:800-900-0444
Practice Address - Fax:949-606-0491
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-30
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45144207QA0401X
CA00G451440207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA49909Medicare UPIN
CA00G451440Medicare PIN