Provider Demographics
NPI:1285925537
Name:DANIELSON, LEROY VICTOR
Entity type:Individual
Prefix:
First Name:LEROY
Middle Name:VICTOR
Last Name:DANIELSON
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 1:14 MAINE ST # 44
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011-2049
Mailing Address - Country:US
Mailing Address - Phone:207-725-9065
Mailing Address - Fax:207-560-9904
Practice Address - Street 1:11 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MACHIAS
Practice Address - State:ME
Practice Address - Zip Code:04654
Practice Address - Country:US
Practice Address - Phone:207-255-3356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2014-0219207P00000X
390200000X
MEMD21872207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program