Provider Demographics
NPI:1275827826
Name:MWANZA, DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MWANZA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3011
Mailing Address - Country:US
Mailing Address - Phone:585-922-4518
Mailing Address - Fax:585-336-5113
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3011
Practice Address - Country:US
Practice Address - Phone:585-922-4518
Practice Address - Fax:585-336-5113
Is Sole Proprietor?:No
Enumeration Date:2011-05-31
Last Update Date:2023-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS9359208600000X, 2086S0127X
IN02003845A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0127XAllopathic & Osteopathic PhysiciansSurgeryTrauma Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200686170AMedicaid
AR218263003Medicaid
AR549012YH5HMedicare PIN