Basic Information
| Provider Information | |||||||||
| NPI: | 1396773941 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DARE | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | P | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 321359 | ||||||||
| Address2: | |||||||||
| City: | FLOWOOD | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392321359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6019361395 | ||||||||
| FaxNumber: | 6016361076 | ||||||||
| Practice Location | |||||||||
| Address1: | 2080 S FRONTAGE RD | ||||||||
| Address2: | SUITE 113 | ||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 391805328 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016361219 | ||||||||
| FaxNumber: | 6016361076 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 08/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 08622 | MS | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1173622 | 05 | LA | MEDICAID | 4357636 | 01 | MS | AETNA | OTHER | 0019377 | 05 | MS | MEDICAID |