Provider Demographics
NPI:1063523819
Name:ALLEN, DANIEL BRADLEY (MD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:BRADLEY
Last Name:ALLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:13847 EAST 14TH STREET
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-2625
Mailing Address - Country:US
Mailing Address - Phone:510-357-7141
Mailing Address - Fax:510-357-4274
Practice Address - Street 1:13847 EAST 14TH STREET
Practice Address - Street 2:SUITE 109
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2625
Practice Address - Country:US
Practice Address - Phone:510-357-7141
Practice Address - Fax:510-357-4274
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG714112086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G714112Medicaid
CA00G714112Medicaid
00G714113Medicare ID - Type Unspecified