Provider Demographics
NPI:1366488736
Name:DANIELSON, CARL LEON III (MD FACS)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:LEON
Last Name:DANIELSON
Suffix:III
Gender:M
Credentials:MD FACS
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Mailing Address - Street 1:50 ROWE STREET
Mailing Address - Street 2:SUITE 400
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176
Mailing Address - Country:US
Mailing Address - Phone:781-665-4462
Mailing Address - Fax:781-620-1930
Practice Address - Street 1:50 ROWE STREET
Practice Address - Street 2:SUITE 400
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176
Practice Address - Country:US
Practice Address - Phone:781-665-4462
Practice Address - Fax:781-620-1930
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2015-03-13
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Provider Licenses
StateLicense IDTaxonomies
MA76101208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
3093719OtherMASSHEALTH
459233OtherAETNA
076101OtherMEDICARE PREFERRED TUFTS
459233OtherUS HEALTHCARE
J12576OtherBLUE CROSS BLUE SHIELD
076101OtherTUFTS HEALTH PLANS
8557OtherHARVARD PILGRIM
MA3093719Medicaid
39271OtherCOST CARE
99028701OtherNETWORK HEALTH
0035205OtherNEIGHBORHOOD HEALTH PLAN
076101OtherTUFTS ASSOCIATED H PLANS
PR12357520001OtherCIGNA
3093719OtherMASSHEALTH