Basic Information
| Provider Information | |||||||||
| NPI: | 1346655396 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ESTRADA | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10736 JEFFERSON BLVD # 307 | ||||||||
| Address2: | |||||||||
| City: | CULVER CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902304933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | 2252301013 | ||||||||
| Practice Location | |||||||||
| Address1: | 1165 MONTGOMERY DR | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954054801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075255300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2014 | ||||||||
| LastUpdateDate: | 10/15/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 31260 | NE | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208100000X | A140441 | CA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 47037660425 | 05 | NE | MEDICAID | 1346655396 | 05 | IA | MEDICAID |