Basic Information
| Provider Information | |||||||||
| NPI: | 1205902442 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FASSETT | ||||||||
| FirstName: | DANIEL | ||||||||
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| Credential: | M.D., M.B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 833 CHESTNUT ST STE 520 | ||||||||
| Address2: | |||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6096777003 | ||||||||
| FaxNumber: | 2673393761 | ||||||||
| Practice Location | |||||||||
| Address1: | 1141 PATTERSON TER | ||||||||
| Address2: | |||||||||
| City: | LAKE MARY | ||||||||
| State: | FL | ||||||||
| PostalCode: | 327462203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444074070 | ||||||||
| FaxNumber: | 4077433050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2006 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 036117618 | IL | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | ME154265 | FL | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 036-117618 | 01 | IL | STATE LICENSE | OTHER |