Provider Demographics
NPI:1053056473
Name:MATHISEN, DANIELLE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE
Last Name:MATHISEN
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 1:4620 FOXFIRE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76133-6232
Mailing Address - Country:US
Mailing Address - Phone:817-980-8875
Mailing Address - Fax:
Practice Address - Street 1:1319 PUNAHOU ST STE 824
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-1032
Practice Address - Country:US
Practice Address - Phone:808-203-6518
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-29
Last Update Date:2022-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMDR-8280390200000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program