Healthcare Provider Details

I. General information

NPI: 1386037356
Provider Name (Legal Business Name): DANIEL BANUELOS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1560 E CHEVY CHASE DR STE 430
GLENDALE CA
91206-4140
US

IV. Provider business mailing address

1560 E CHEVY CHASE DR STE 430
GLENDALE CA
91206-4140
US

V. Phone/Fax

Practice location:
  • Phone: 818-243-1135
  • Fax:
Mailing address:
  • Phone: 661-343-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA200571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: