Provider Demographics
NPI:1861804247
Name:BURGESS, DANIEL (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:BURGESS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10903 DERRYDOWN WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2898
Mailing Address - Country:US
Mailing Address - Phone:610-573-4707
Mailing Address - Fax:
Practice Address - Street 1:477 N EL CAMINO REAL STE C204
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1332
Practice Address - Country:US
Practice Address - Phone:858-207-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-20
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A18163208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program