Provider Demographics
NPI:1609804160
Name:DISANDRO, DANIEL G (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:G
Last Name:DISANDRO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 COOPER PLZ
Mailing Address - Street 2:SUITE 500
Mailing Address - City:CAMDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:08103-1438
Mailing Address - Country:US
Mailing Address - Phone:856-342-2627
Mailing Address - Fax:
Practice Address - Street 1:3 COOPER PLZ
Practice Address - Street 2:SUITE 500
Practice Address - City:CAMDEN
Practice Address - State:NJ
Practice Address - Zip Code:08103-1438
Practice Address - Country:US
Practice Address - Phone:856-342-2627
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD056868L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015577760Medicaid
PA869945OtherBS
1037820OtherKEYSTONE MERCY
PA869945OtherHIGHMARK BS
PA0015577760007OtherPROMISE
PA0985174000OtherKEYSTONE
PA869945JTKMedicare PIN
PA869945OtherBS
PAG30898Medicare UPIN