Provider Demographics
NPI:1003556515
Name:LINGGONEGORO, DANNY
Entity Type:Individual
Prefix:
First Name:DANNY
Middle Name:
Last Name:LINGGONEGORO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 BROADWAY ST FL C2
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94063-3132
Mailing Address - Country:US
Mailing Address - Phone:650-721-7190
Mailing Address - Fax:
Practice Address - Street 1:450 BROADWAY ST FL C2
Practice Address - Street 2:
Practice Address - City:REDWOOD CITY
Practice Address - State:CA
Practice Address - Zip Code:94063-3132
Practice Address - Country:US
Practice Address - Phone:650-721-7190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-31
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA293781208000000X
390200000X
CAA191221207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program