Provider Demographics
NPI:1629038195
Name:DANIELSON, STANTON L (MD)
Entity Type:Individual
Prefix:
First Name:STANTON
Middle Name:L
Last Name:DANIELSON
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 1:2720 8TH ST SW
Mailing Address - Street 2:
Mailing Address - City:ALTOONA
Mailing Address - State:IA
Mailing Address - Zip Code:50009-1028
Mailing Address - Country:US
Mailing Address - Phone:515-967-0133
Mailing Address - Fax:515-967-7578
Practice Address - Street 1:2720 8TH ST SW
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:IA
Practice Address - Zip Code:50009-1028
Practice Address - Country:US
Practice Address - Phone:515-967-0133
Practice Address - Fax:515-967-7578
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20683207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3161448Medicaid
IA1629038195Medicaid
IA719260379Medicare PIN
IA13337Medicare PIN
IAP00273990Medicare PIN
IAA01434Medicare UPIN