Provider Demographics
NPI:1629197363
Name:TRAN, DANIELLE (MD)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:
Last Name:TRAN
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 1:39 WALLACE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106-6143
Mailing Address - Country:US
Mailing Address - Phone:207-761-0650
Mailing Address - Fax:207-761-8198
Practice Address - Street 1:193 MAIN ST
Practice Address - Street 2:SUITE 9
Practice Address - City:NORWAY
Practice Address - State:ME
Practice Address - Zip Code:04268-5645
Practice Address - Country:US
Practice Address - Phone:207-743-8766
Practice Address - Fax:207-743-1579
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME015390208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME314710099Medicaid