Basic Information
| Provider Information | |||||||||
| NPI: | 1215298104 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PUCHERIL | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | THOMAS | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D., M.B.A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3737 SOUTHERN BLVD STE 4200 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454290135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372941489 | ||||||||
| FaxNumber: | 9372947999 | ||||||||
| Practice Location | |||||||||
| Address1: | 3737 SOUTHERN BLVD STE 4200 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454290135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9372941489 | ||||||||
| FaxNumber: | 9372947999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2012 | ||||||||
| LastUpdateDate: | 01/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 4301100400 | MI | N | Allopathic & Osteopathic Physicians | Urology | 208800000X | 35.134964 | OH | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 0359824 | 05 | OH | MEDICAID |