Provider Demographics
NPI:1104807973
Name:TACKABURY, DANIEL E (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:E
Last Name:TACKABURY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:401 S BALLENGER HWY
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-3638
Mailing Address - Country:US
Mailing Address - Phone:810-342-1000
Mailing Address - Fax:810-342-1590
Practice Address - Street 1:3789 HURON ST
Practice Address - Street 2:
Practice Address - City:NORTH BRANCH
Practice Address - State:MI
Practice Address - Zip Code:48461-8117
Practice Address - Country:US
Practice Address - Phone:810-688-3093
Practice Address - Fax:810-688-3964
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070116207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA253174OtherMCLAREN HEALTH PLAN
MAC7436OtherMCARE
MA253174OtherHEALTH ADVANTAGE NETWORK
MI4226712Medicaid
MA0988276OtherHEALTH PLUS
MI6872693001OtherCIGNA
MI7936230OtherAETNA
MIH21189OtherHEALTH ALLIANCE PLAN
MIH21189OtherHEALTH NET FEDERAL SERV
MA253174OtherMCLAREN HEALTH PLAN
MAC7436OtherMCARE