Basic Information
| Provider Information | |||||||||
| NPI: | 1609804160 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DISANDRO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422627 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3 COOPER PLZ | ||||||||
| Address2: | SUITE 500 | ||||||||
| City: | CAMDEN | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 081031438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8563422627 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/30/2006 | ||||||||
| LastUpdateDate: | 04/22/2016 | ||||||||
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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 | 207P00000X | MD056868L | PA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0015577760 | 05 | PA | MEDICAID | 869945 | 01 | PA | BS | OTHER | 1037820 | 01 | KEYSTONE MERCY | OTHER | 869945 | 01 | PA | HIGHMARK BS | OTHER | 0015577760007 | 01 | PA | PROMISE | OTHER | 0985174000 | 01 | PA | KEYSTONE | OTHER |