Basic Information
Provider Information | |||||||||
NPI: | 1679550123 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KULICK | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26800 CROWN VALLEY PKWY STE 120 | ||||||||
Address2: |   | ||||||||
City: | MISSION VIEJO | ||||||||
State: | CA | ||||||||
PostalCode: | 926918033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9493643388 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 26800 CROWN VALLEY PKWY | ||||||||
Address2: | SUITE 120 | ||||||||
City: | MISSION VIEJO | ||||||||
State: | CA | ||||||||
PostalCode: | 926916384 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9493643388 | ||||||||
FaxNumber: | 9493645026 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/27/2005 | ||||||||
LastUpdateDate: | 11/05/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/05/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | G47622 | CA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | G47622 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology |
ID Information
ID | Type | State | Issuer | Description | 00G476220 | 05 | CA |   | MEDICAID |