Provider Demographics
NPI:1003850413
Name:NAM, DANIEL (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:NAM
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:160 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2114
Practice Address - Country:US
Practice Address - Phone:845-858-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07999200207R00000X
PAMD432587207R00000X
NY306510207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020277300003Medicaid
PA1020277300001Medicaid
PA1020277300002Medicaid
PA3432839000OtherBCBS OF PA
PA2089031OtherHIGHMARK BLUE SHIELD
PA121631VYNMedicare PIN