Healthcare Provider Details

I. General information

NPI: 1295762326
Provider Name (Legal Business Name): BENJAMIN DOMINGO DACULA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 11/29/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 E AVENUE S
PALMDALE CA
93552-4480
US

IV. Provider business mailing address

4502 E AVENUE S
PALMDALE CA
93552-4480
US

V. Phone/Fax

Practice location:
  • Phone: 877-554-4404
  • Fax:
Mailing address:
  • Phone: 877-554-4404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40182
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25149
License Number StateOK
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC54857
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: