Provider Demographics
NPI:1194052100
Name:DAUDEL PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:DAUDEL PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:J.
Authorized Official - Middle Name:LINN
Authorized Official - Last Name:DAUDEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:415-331-8390
Mailing Address - Street 1:175 N REDWOOD DR
Mailing Address - Street 2:STE 275
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-1942
Mailing Address - Country:US
Mailing Address - Phone:415-331-8390
Mailing Address - Fax:415-331-8380
Practice Address - Street 1:1100 ROSE DR
Practice Address - Street 2:STE 140
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-3623
Practice Address - Country:US
Practice Address - Phone:707-745-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-11
Last Update Date:2009-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA95421207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty