Healthcare Provider Details

I. General information

NPI: 1487034211
Provider Name (Legal Business Name): DANIEL LIDDELL M.D,
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2015
Last Update Date: 04/30/2024
Certification Date: 04/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HEALTH CLINIC OAK HARBOR 3475 N SARATOGA ST
OAK HARBOR WA
98278-0001
US

IV. Provider business mailing address

22 AREA MARINE CENTERED MEDICAL HOME BLDG 22190
CAMP PENDLETON CA
92055
US

V. Phone/Fax

Practice location:
  • Phone: 603-257-9915
  • Fax:
Mailing address:
  • Phone: 760-725-3784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number29467
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: