Provider Demographics
NPI:1679550123
Name:KULICK, DANIEL L (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:L
Last Name:KULICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26800 CROWN VALLEY PKWY STE 120
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-8033
Mailing Address - Country:US
Mailing Address - Phone:949-364-3388
Mailing Address - Fax:
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 120
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-364-3388
Practice Address - Fax:949-364-5026
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47622207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G476220Medicaid
CAWG47622CMedicare PIN
CAE02674Medicare UPIN
CAAR213YMedicare PIN