Provider Demographics
NPI:1316236698
Name:HUMPHREYS, DANIEL E (DO)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:E
Last Name:HUMPHREYS
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 1:950 N. MERIDIAN STREET
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-963-0860
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:ROOM DG412
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-3886
Practice Address - Fax:317-963-5492
Is Sole Proprietor?:No
Enumeration Date:2011-04-07
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN01071385A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201102240Medicaid
IN201102240Medicaid