Provider Demographics
NPI:1104869353
Name:DANIELSON, DIRK H (MD)
Entity type:Individual
Prefix:DR
First Name:DIRK
Middle Name:H
Last Name:DANIELSON
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 1:200 CORPORATE BLVD.
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:801GOODYEAR BLVD.
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3221
Practice Address - Country:US
Practice Address - Phone:601-452-9690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2010-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS13167207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP00388803OtherRAILROAD MCARE THRU IHS
MSP00806413OtherRRMCARE THRU HCCN
MS00125003Medicaid
MSP00806413OtherRRMCARE THRU HCCN
MS930003951Medicare PIN
MS93003262Medicare ID - Type Unspecified
MS302I931482Medicare PIN