Healthcare Provider Details

I. General information

NPI: 1700091113
Provider Name (Legal Business Name): DANIELLE K MOUL M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 09/22/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 BROADWAY ST STE 104 PMB 135
LAGUNA BEACH CA
92651
US

IV. Provider business mailing address

303 BROADWAY SUITE 104 PMB 135
LAGUNA BEACH CA
92651
US

V. Phone/Fax

Practice location:
  • Phone: 410-952-6996
  • Fax:
Mailing address:
  • Phone: 949-715-5676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number57.007895
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA104213
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License NumberA104213
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: