Provider Demographics
NPI:1376655456
Name:DANIELISZ, PETRA (MD)
Entity Type:Individual
Prefix:DR
First Name:PETRA
Middle Name:
Last Name:DANIELISZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 INNSBRUCK DR
Mailing Address - Street 2:
Mailing Address - City:EMPORIUM
Mailing Address - State:PA
Mailing Address - Zip Code:15834-3841
Mailing Address - Country:US
Mailing Address - Phone:814-486-2046
Mailing Address - Fax:
Practice Address - Street 1:81 CLARION RD
Practice Address - Street 2:
Practice Address - City:JOHNSONBURG
Practice Address - State:PA
Practice Address - Zip Code:15845-1656
Practice Address - Country:US
Practice Address - Phone:814-389-4411
Practice Address - Fax:814-389-4142
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD062597L207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007763960007Medicaid
PAG61661Medicare UPIN
PA1007763960007Medicaid