Provider Demographics
NPI:1043870868
Name:VANBECKUM, DANIELLE ROSE (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ROSE
Last Name:VANBECKUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 EAST MEDICAL CENTER DR
Mailing Address - Street 2:MPB D3230 SPC 5718
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48109-5718
Mailing Address - Country:US
Mailing Address - Phone:734-647-1774
Mailing Address - Fax:
Practice Address - Street 1:1500 EAST MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48109-5718
Practice Address - Country:US
Practice Address - Phone:734-647-1774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-14
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351045106208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4351045106OtherLIMITED EDUCATION LICENSE
MI5315207211OtherCONTROLLED SUBSTANCE LICENSE