Provider Demographics
NPI:1093714958
Name:JORGENSON, DANIEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:S
Last Name:JORGENSON
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 1:20 ARROWOOD DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1857
Mailing Address - Country:US
Mailing Address - Phone:607-216-0062
Mailing Address - Fax:
Practice Address - Street 1:20 ARROWOOD DR
Practice Address - Street 2:SUITE B
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1857
Practice Address - Country:US
Practice Address - Phone:607-216-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY228554208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
F37789Medicare UPIN