Provider Demographics
NPI:1225145196
Name:PALMER, DANIEL W JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:W
Last Name:PALMER
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:MRS
Other - First Name:LILIA
Other - Middle Name:C
Other - Last Name:PALMER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2205 VIRGINIA AVE
Mailing Address - Street 2:
Mailing Address - City:CONNERSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47331-4314
Mailing Address - Country:US
Mailing Address - Phone:765-827-8064
Mailing Address - Fax:765-825-6999
Practice Address - Street 1:120 NE GLEN OAK AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61603-4314
Practice Address - Country:US
Practice Address - Phone:309-672-3158
Practice Address - Fax:309-672-3114
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-24
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036085061174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-1297307OtherTAX ID NUMBER
ILE07205Medicare UPIN
IL983260Medicare ID - Type Unspecified