Basic Information
| Provider Information | |||||||||
| NPI: | 1740531011 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DSTTEFFANO | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 S FLORIDA ST | ||||||||
| Address2: | CLARK CLINIC INC | ||||||||
| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527932441 | ||||||||
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| Practice Location | |||||||||
| Address1: | 212 S FLORIDA ST | ||||||||
| Address2: | CLARK CLINIC INC | ||||||||
| City: | BUSHNELL | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335136703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3527932441 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2012 | ||||||||
| LastUpdateDate: | 06/18/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 18562 | PR | Y | Allopathic & Osteopathic Physicians | General Practice | 208D00000X | ACN543 | FL | N | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.