Provider Demographics
NPI:1225572365
Name:CORDOBA, DANIEL
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:CORDOBA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 HAWTHORNE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:CHELSEA
Mailing Address - State:MA
Mailing Address - Zip Code:02150-3411
Mailing Address - Country:US
Mailing Address - Phone:203-273-7571
Mailing Address - Fax:
Practice Address - Street 1:59 HAWTHORNE ST APT 2
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MA
Practice Address - Zip Code:02150-3411
Practice Address - Country:US
Practice Address - Phone:203-273-7571
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-08
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
MA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer