Provider Demographics
NPI:1508824640
Name:ACEVEDO-DANIELS, SUHREI (MD)
Entity Type:Individual
Prefix:
First Name:SUHREI
Middle Name:
Last Name:ACEVEDO-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:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-495-1011
Mailing Address - Fax:208-495-1012
Practice Address - Street 1:150 2ND ST
Practice Address - Street 2:
Practice Address - City:MELBA
Practice Address - State:ID
Practice Address - Zip Code:83641-5199
Practice Address - Country:US
Practice Address - Phone:208-495-1011
Practice Address - Fax:208-495-1012
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1215106695Medicaid
ID1370114Medicare PIN
CA00A776050Medicare ID - Type UnspecifiedMEDICARE ID NUMBER