Provider Demographics
NPI:1699970566
Name:BRANAM, DANIEL GEORGE (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:GEORGE
Last Name:BRANAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 80070
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-0070
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:5001 US HIGHWAY 30 W STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9701
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4969
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2016-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01059886A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1699970566Medicaid
IN200911720Medicaid
OH2884320Medicaid
INP00787716Medicare PIN
IN981270BBBMedicare PIN
MIMI1209026Medicare PIN
IN200911720Medicaid
HIDC989ZMedicare PIN