Provider Demographics
NPI:1326230236
Name:JENSEN, DANIEL LORAN (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:LORAN
Last Name:JENSEN
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:PO BOX 6739195
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-3937
Mailing Address - Country:US
Mailing Address - Phone:810-720-5715
Mailing Address - Fax:810-732-0891
Practice Address - Street 1:27500 HOOVER RD
Practice Address - Street 2:STE 100
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-4586
Practice Address - Country:US
Practice Address - Phone:586-754-2558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010151552086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP49000002Medicare PIN