Provider Demographics
NPI:1508202995
Name:EDET DANIELS, ITORO BASSEY (MD)
Entity Type:Individual
Prefix:
First Name:ITORO
Middle Name:BASSEY
Last Name:EDET DANIELS
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 1:803 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30642-1211
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:803 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:GA
Practice Address - Zip Code:30642
Practice Address - Country:US
Practice Address - Phone:706-454-5114
Practice Address - Fax:706-454-5199
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-13
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR73852207R00000X, 208000000X
GA080742207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics