Provider Demographics
NPI:1063866986
Name:ROSENBLAT, DANIEL TODD
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:TODD
Last Name:ROSENBLAT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3981
Mailing Address - Country:US
Mailing Address - Phone:217-366-5434
Mailing Address - Fax:217-366-8074
Practice Address - Street 1:1801 W WINDSOR RD
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61822-6217
Practice Address - Country:US
Practice Address - Phone:217-366-5434
Practice Address - Fax:217-366-8074
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-18
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036169884207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program