1497813133 NPI number — MR. STEPHEN J DAILLAK RPT

Table of content: MR. STEPHEN J DAILLAK RPT (NPI 1497813133)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497813133 NPI number — MR. STEPHEN J DAILLAK RPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DAILLAK
Provider First Name:
STEPHEN
Provider Middle Name:
J
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
RPT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497813133
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1191 CRESTON RD STE 115
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASO ROBLES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93446-3033
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-239-3696
Provider Business Mailing Address Fax Number:
805-239-3697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1191 CRESTON RD STE 115
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASO ROBLES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93446-3033
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-239-3696
Provider Business Practice Location Address Fax Number:
805-239-3697
Provider Enumeration Date:
12/05/2006

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: 208100000X , with the licence number:  PT27175 , 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)

  • Identifier: OPT271750 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: ZZZ06333Z . This is a "BLUE SHIELD GROUP" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PT27175 . This is a "BLUE CROSS" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: GPT001411 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: PT27175 . This is a "TRICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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