Provider Demographics
NPI:1609906478
Name:HALLISSY, DANIEL JOSEPH (DPM)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOSEPH
Last Name:HALLISSY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SLAYTON RD
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176-4222
Mailing Address - Country:US
Mailing Address - Phone:781-662-6196
Mailing Address - Fax:617-361-3297
Practice Address - Street 1:52 CREST AVE
Practice Address - Street 2:
Practice Address - City:WINTHROP
Practice Address - State:MA
Practice Address - Zip Code:02152-1064
Practice Address - Country:US
Practice Address - Phone:617-539-0197
Practice Address - Fax:617-539-0669
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2016-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAMA2135213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0326526Medicaid
MAHAY75074Medicare ID - Type Unspecified
MAU78004Medicare UPIN