Basic Information
Provider Information | |||||||||
NPI: | 1194052100 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | DAUDEL PROFESSIONAL MEDICAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 175 N REDWOOD DR | ||||||||
Address2: | STE 275 | ||||||||
City: | SAN RAFAEL | ||||||||
State: | CA | ||||||||
PostalCode: | 949031942 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4153318390 | ||||||||
FaxNumber: | 4153318380 | ||||||||
Practice Location | |||||||||
Address1: | 1100 ROSE DR | ||||||||
Address2: | STE 140 | ||||||||
City: | BENICIA | ||||||||
State: | CA | ||||||||
PostalCode: | 945103623 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7077453700 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2009 | ||||||||
LastUpdateDate: | 11/11/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DAUDEL | ||||||||
AuthorizedOfficialFirstName: | J. | ||||||||
AuthorizedOfficialMiddleName: | LINN | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 4153318390 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VX0000X | A95421 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics |
No ID Information.