Healthcare Provider Details

I. General information

NPI: 1770649816
Provider Name (Legal Business Name): DANIEL J HEADRICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/30/2006
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32301 CAMINO CAPISTRANO STE J
SAN JUAN CAPISTRANO CA
92675-4512
US

IV. Provider business mailing address

PO BOX 6747
HUNTINGTON BEACH CA
92615-6747
US

V. Phone/Fax

Practice location:
  • Phone: 800-900-0444
  • Fax: 949-606-0491
Mailing address:
  • Phone: 714-377-3749
  • Fax: 714-377-5642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License NumberG45144
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number00G451440
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: