Provider Demographics
NPI:1073951497
Name:CORSON-KNOWLES, DANIEL R (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:R
Last Name:CORSON-KNOWLES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 N SENATE BLVD
Mailing Address - Street 2:AG012
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-1239
Mailing Address - Country:US
Mailing Address - Phone:317-962-5975
Mailing Address - Fax:317-962-5394
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:AG012
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-5975
Practice Address - Fax:317-962-5394
Is Sole Proprietor?:No
Enumeration Date:2013-06-07
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11017213A390200000X
IN01075938A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201169590Medicaid
IN200640029Medicare PIN
IN201169590Medicaid
IN264430354Medicare PIN