Provider Demographics
NPI:1972352367
Name:DANN, DOUGLAS DYLAN
Entity type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:DYLAN
Last Name:DANN
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 1:5548 W TICE CT
Mailing Address - Street 2:
Mailing Address - City:HOMOSASSA
Mailing Address - State:FL
Mailing Address - Zip Code:34446-2422
Mailing Address - Country:US
Mailing Address - Phone:352-807-2284
Mailing Address - Fax:
Practice Address - Street 1:5548 W TICE CT
Practice Address - Street 2:
Practice Address - City:HOMOSASSA
Practice Address - State:FL
Practice Address - Zip Code:34446-2422
Practice Address - Country:US
Practice Address - Phone:352-807-2284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-16
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL172A00000X
FLD500164714280172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver