Provider Demographics
NPI:1275976680
Name:BAL, DANIEL JONATHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JONATHAN
Last Name:BAL
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 1:75 HOLLY HILL LN FL 2
Mailing Address - Street 2:
Mailing Address - City:GREENWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06830-2917
Mailing Address - Country:US
Mailing Address - Phone:203-869-6960
Mailing Address - Fax:
Practice Address - Street 1:75 HOLLY HILL LN FL 2
Practice Address - Street 2:
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830
Practice Address - Country:US
Practice Address - Phone:203-869-6960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-16
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT60170207Q00000X
CTAS2383278-0839390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine