Provider Demographics
NPI:1104966720
Name:DANIELSON, JOHN R (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
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 1:8053 CLEVELAND PL
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-5303
Mailing Address - Country:US
Mailing Address - Phone:219-769-4456
Mailing Address - Fax:219-769-1468
Practice Address - Street 1:8053 CLEVELAND PL
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-5303
Practice Address - Country:US
Practice Address - Phone:219-769-4456
Practice Address - Fax:219-769-1468
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01034603208200000X
IN01034603A2082S0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100201750AMedicaid
IN240000555OtherRAILROAD MEDICARE
000000095467OtherANTHEM
IN705130Medicare PIN
IN100201750AMedicaid