Basic Information
| Provider Information | |||||||||
| NPI: | 1154374122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DANIELS | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 970 EMBARCADERO DEL MAR | ||||||||
| Address2: | |||||||||
| City: | ISLA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931174869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059681511 | ||||||||
| FaxNumber: | 8056852467 | ||||||||
| Practice Location | |||||||||
| Address1: | 970 EMBARCADERO DEL MAR | ||||||||
| Address2: | |||||||||
| City: | ISLA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931174869 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059681511 | ||||||||
| FaxNumber: | 8056852467 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2006 | ||||||||
| LastUpdateDate: | 10/24/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G34858 | CA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | G34858 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G348580 | 05 | CA | MEDICAID |