Provider Demographics
NPI:1356846554
Name:BRISSETT, DANIELA IRIS
Entity Type:Individual
Prefix:
First Name:DANIELA
Middle Name:IRIS
Last Name:BRISSETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 16TH ST FL 4
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2549
Mailing Address - Country:US
Mailing Address - Phone:415-476-6245
Mailing Address - Fax:415-476-5354
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-327-4307
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-28
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT2222132080A0000X
390200000X
PAMD4754772080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program