Basic Information
Provider Information | |||||||||
NPI: | 1740266493 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DANIELS | ||||||||
FirstName: | INDRA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1315 BROADWAY | ||||||||
Address2: | UNIT B SUITE 120 | ||||||||
City: | HEWLETT | ||||||||
State: | NY | ||||||||
PostalCode: | 115572115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5162554200 | ||||||||
FaxNumber: | 5165942623 | ||||||||
Practice Location | |||||||||
Address1: | 1 HEALTHY WAY | ||||||||
Address2: |   | ||||||||
City: | OCEANSIDE | ||||||||
State: | NY | ||||||||
PostalCode: | 115721551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5166324398 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/15/2005 | ||||||||
LastUpdateDate: | 07/21/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 187876 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology | 207RH0002X | 187876 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hospice and Palliative Medicine |
ID Information
ID | Type | State | Issuer | Description | 01851367 | 05 | NY |   | MEDICAID |