Provider Demographics
NPI:1225001068
Name:DANIELSON, MARK V (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:V
Last Name:DANIELSON
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 1:2 UNO CIR
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6653
Mailing Address - Country:US
Mailing Address - Phone:815-725-2277
Mailing Address - Fax:815-725-7870
Practice Address - Street 1:2 UNO CIR
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6653
Practice Address - Country:US
Practice Address - Phone:815-725-2277
Practice Address - Fax:815-725-7870
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072694174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL020047471OtherRRMC
IL036072694Medicaid
IL020047471OtherRRMC