Basic Information
| Provider Information | |||||||||
| NPI: | 1316236698 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMPHREYS | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 950 N. MERIDIAN STREET | ||||||||
| Address2: | STE 500 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462043908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179630860 | ||||||||
| FaxNumber: | 3179624950 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 N SENATE BLVD | ||||||||
| Address2: | ROOM DG412 | ||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462021239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3179623886 | ||||||||
| FaxNumber: | 3179635492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2011 | ||||||||
| LastUpdateDate: | 08/15/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 01071385A | IN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 201102240 | 05 | IN | MEDICAID |