Provider Demographics
NPI:1699749044
Name:CHANNELL, DANIEL B (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:B
Last Name:CHANNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8008 HAVEN AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3047
Mailing Address - Country:US
Mailing Address - Phone:909-483-1236
Mailing Address - Fax:909-483-1465
Practice Address - Street 1:8008 HAVEN AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3047
Practice Address - Country:US
Practice Address - Phone:909-483-1236
Practice Address - Fax:909-483-1465
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2011-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG85321207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADJ884YMedicare PIN
G40726Medicare UPIN
00G853210Medicare ID - Type Unspecified