Basic Information
Provider Information | |||||||||
NPI: | 1912944232 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PATRICK | ||||||||
FirstName: | DANIEL | ||||||||
MiddleName: | S | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6102 | ||||||||
Address2: |   | ||||||||
City: | NOVATO | ||||||||
State: | CA | ||||||||
PostalCode: | 949486102 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4158843404 | ||||||||
FaxNumber: | 4158831836 | ||||||||
Practice Location | |||||||||
Address1: | 1303 E HERNDON AVE | ||||||||
Address2: | SUITE 200 | ||||||||
City: | FRESNO | ||||||||
State: | CA | ||||||||
PostalCode: | 937203309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5594503109 | ||||||||
FaxNumber: | 5594503674 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/02/2006 | ||||||||
LastUpdateDate: | 12/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207UN0902X | A92101 | CA | Y |   | Allopathic & Osteopathic Physicians | Nuclear Medicine | Nuclear Imaging & Therapy |
ID Information
ID | Type | State | Issuer | Description | 00A921010 | 05 | CA |   | MEDICAID | P00243797 | 01 |   | RAILROAD MEDICARE PIN | OTHER |