Provider Demographics
NPI:1144428103
Name:KASSAVIN, DANIEL S (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:S
Last Name:KASSAVIN
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 1:2330 EUCLID HEIGHTS BLVD
Mailing Address - Street 2:APT 306
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44106-2728
Mailing Address - Country:US
Mailing Address - Phone:716-704-3301
Mailing Address - Fax:
Practice Address - Street 1:MEDINA MEDICAL OFFICE BUILDING / SOUTH
Practice Address - Street 2:970 E WASHINGTON ST STE 4B
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2181
Practice Address - Country:US
Practice Address - Phone:330-721-5700
Practice Address - Fax:330-721-5287
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2019-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.1272582086S0129X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03643309Medicaid
NY03643309Medicaid