Basic Information
| Provider Information | |||||||||
| NPI: | 1467679472 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INDRA D. DANIELS PHYSICIAN PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1315 BROADWAY UNIT B SUITE 120 | ||||||||
| Address2: | |||||||||
| City: | HEWLETT | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162554200 | ||||||||
| FaxNumber: | 5165942623 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 N. VILLAGE AVE SUITE 314 | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5162554200 | ||||||||
| FaxNumber: | 5165942623 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2007 | ||||||||
| LastUpdateDate: | 10/22/2007 | ||||||||
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| AuthorizedOfficialLastName: | DANIELS | ||||||||
| AuthorizedOfficialFirstName: | INDRA | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5162554200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHYSICIAN PLLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 187876 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 01851367 | 05 | NY | MEDICAID |