Provider Demographics
NPI:1598147092
Name:FOSSELMAN, DANIEL S (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:S
Last Name:FOSSELMAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 ALTAIR PKWY STE 3300
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-7653
Mailing Address - Country:US
Mailing Address - Phone:614-882-0708
Mailing Address - Fax:614-882-2878
Practice Address - Street 1:400 ALTAIR PKWY STE 3300
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-7653
Practice Address - Country:US
Practice Address - Phone:614-882-0708
Practice Address - Fax:614-882-2878
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.012407207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0342372Medicaid