1366488736 NPI number — CARL LEON DANIELSON III MD FACS

Table of content: CARL LEON DANIELSON III MD FACS (NPI 1366488736)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366488736 NPI number — CARL LEON DANIELSON III MD FACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DANIELSON
Provider First Name:
CARL
Provider Middle Name:
LEON
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD FACS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1366488736
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
50 ROWE STREET
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
MELROSE
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02176
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
781-665-4462
Provider Business Mailing Address Fax Number:
781-620-1930

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 ROWE STREET
Provider Second Line Business Practice Location Address:
SUITE 400
Provider Business Practice Location Address City Name:
MELROSE
Provider Business Practice Location Address State Name:
MA
Provider Business Practice Location Address Postal Code:
02176
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
781-665-4462
Provider Business Practice Location Address Fax Number:
781-620-1930
Provider Enumeration Date:
06/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  76101 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3093719 . This is a "MASSHEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 459233 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 076101 . This is a "MEDICARE PREFERRED TUFTS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 459233 . This is a "US HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: J12576 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 076101 . This is a "TUFTS HEALTH PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8557 . This is a "HARVARD PILGRIM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3093719 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 39271 . This is a "COST CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 99028701 . This is a "NETWORK HEALTH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 0035205 . This is a "NEIGHBORHOOD HEALTH PLAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 076101 . This is a "TUFTS ASSOCIATED H PLANS" identifier . This identifiers is of the category "OTHER".
  • Identifier: PR12357520001 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".




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