Healthcare Provider Details

I. General information

NPI: 1023933488
Provider Name (Legal Business Name): DAN ANGELO GONZALO SURDILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2026
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HARBOR DR
SAN DIEGO CA
92101-7049
US

IV. Provider business mailing address

7845 WESTSIDE DR APT 459
SAN DIEGO CA
92108-1262
US

V. Phone/Fax

Practice location:
  • Phone: 619-395-2582
  • Fax:
Mailing address:
  • Phone: 619-395-2582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number89985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: