Provider Demographics
NPI:1154396802
Name:MAYDONOVITCH, DANIEL J (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:MAYDONOVITCH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 N WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:BOYERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19512-1467
Mailing Address - Country:US
Mailing Address - Phone:610-367-2259
Mailing Address - Fax:610-367-0505
Practice Address - Street 1:23 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:BOYERTOWN
Practice Address - State:PA
Practice Address - Zip Code:19512-1467
Practice Address - Country:US
Practice Address - Phone:610-367-2259
Practice Address - Fax:610-367-0505
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007688L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
80053377Medicare PIN
702510Medicare ID - Type Unspecified
A67385Medicare UPIN