Basic Information
| Provider Information | |||||||||
| NPI: | 1710090915 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DONOFRIO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DONOFRIO | ||||||||
| OtherFirstName: | DANIEL | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 130 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048263469 | ||||||||
| FaxNumber: | 9048084608 | ||||||||
| Practice Location | |||||||||
| Address1: | 130 HEALTH PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT AUGUSTINE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320865776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9048263469 | ||||||||
| FaxNumber: | 9048084608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA2674 | FL | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 002785 | GA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.