Provider Demographics
NPI:1215298104
Name:PUCHERIL, DANIEL THOMAS (MD, MBA)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:THOMAS
Last Name:PUCHERIL
Suffix:
Gender:M
Credentials:MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 SOUTHERN BLVD STE 4200
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-0135
Mailing Address - Country:US
Mailing Address - Phone:937-294-1489
Mailing Address - Fax:937-294-7999
Practice Address - Street 1:3737 SOUTHERN BLVD STE 4200
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-0135
Practice Address - Country:US
Practice Address - Phone:937-294-1489
Practice Address - Fax:937-294-7999
Is Sole Proprietor?:No
Enumeration Date:2012-06-06
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301100400208800000X
OH35.134964208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0359824Medicaid