1376797795 NPI number — MRS. DANIELL BENNETT POLLACK PA-C

Table of content: MRS. DANIELL BENNETT POLLACK PA-C (NPI 1376797795)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376797795 NPI number — MRS. DANIELL BENNETT POLLACK PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
POLLACK
Provider First Name:
DANIELL
Provider Middle Name:
BENNETT
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BENNETT
Provider Other First Name:
DANIELL
Provider Other Middle Name:
MARGARET
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376797795
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/07/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4065 3RD AVENUE
Provider Second Line Business Mailing Address:
SUITE 102
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92103-2184
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-542-0013
Provider Business Mailing Address Fax Number:
619-542-0559

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4065 3RD AVENUE
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92103-2184
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-542-0013
Provider Business Practice Location Address Fax Number:
619-542-0559
Provider Enumeration Date:
11/12/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363AM0700X , with the licence number:  PA20005 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: PA2005 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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