Provider Demographics
NPI:1265468466
Name:DANIELSON, THEMEN S JR (MD)
Entity Type:Individual
Prefix:DR
First Name:THEMEN
Middle Name:S
Last Name:DANIELSON
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:9780 LANTERN RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FISHERS
Mailing Address - State:IN
Mailing Address - Zip Code:46037-4092
Mailing Address - Country:US
Mailing Address - Phone:317-578-4213
Mailing Address - Fax:317-578-9511
Practice Address - Street 1:9780 LANTERN RD
Practice Address - Street 2:SUITE 210
Practice Address - City:FISHERS
Practice Address - State:IN
Practice Address - Zip Code:46037-4092
Practice Address - Country:US
Practice Address - Phone:317-578-4213
Practice Address - Fax:317-578-9511
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01025278A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000383565OtherANTHEM
10781256OtherCAQH
IN01025278OtherIN STATE LIC NUMBER
IN798900DMedicare ID - Type Unspecified
10781256OtherCAQH