Provider Demographics
NPI:1285620773
Name:DANIELS, BERTHA H (MD)
Entity type:Individual
Prefix:DR
First Name:BERTHA
Middle Name:H
Last Name:DANIELS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1101 MEDICAL CENTER BLVD
Mailing Address - Street 2:ATTN: HEIDI GWINN
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3147
Mailing Address - Country:US
Mailing Address - Phone:504-349-1297
Mailing Address - Fax:504-349-1146
Practice Address - Street 1:175 HECTOR AVE
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056-2590
Practice Address - Country:US
Practice Address - Phone:504-349-6925
Practice Address - Fax:504-362-5310
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA023621207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1482731Medicaid
LAH25824Medicare UPIN
LA5H763Medicare ID - Type Unspecified