Provider Demographics
NPI:1194133041
Name:ITANO, DANIEL (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:ITANO
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 1:5870 HIATUS RD
Mailing Address - Street 2:
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33321-6424
Mailing Address - Country:US
Mailing Address - Phone:888-447-2362
Mailing Address - Fax:865-560-7110
Practice Address - Street 1:101 CIVIC CENTER LN
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-5607
Practice Address - Country:US
Practice Address - Phone:928-855-8185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ008447207Q00000X
NVDO2126207Q00000X
CA20A13692207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA050586Medicare PIN