Healthcare Provider Details

I. General information

NPI: 1346351665
Provider Name (Legal Business Name): STEPHEN M DAQUINO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/29/2020
Certification Date: 07/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16445 BERNARDO CENTER DR
SAN DIEGO CA
92128-2523
US

IV. Provider business mailing address

16445 BERNARDO CENTER DR
SAN DIEGO CA
92128-2523
US

V. Phone/Fax

Practice location:
  • Phone: 858-429-0099
  • Fax: 866-266-8027
Mailing address:
  • Phone: 858-429-0099
  • Fax: 866-266-8027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A8442
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: