Provider Demographics
NPI:1710920830
Name:MCCALLY, DANIEL (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MCCALLY
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 1:155 W MERRICK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-3743
Mailing Address - Country:US
Mailing Address - Phone:516-867-0102
Mailing Address - Fax:516-867-1857
Practice Address - Street 1:155 W MERRICK RD STE 204
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-3743
Practice Address - Country:US
Practice Address - Phone:516-867-0102
Practice Address - Fax:516-867-1857
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115718208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00425750Medicaid
340002520OtherPALMETTO GBA/RAILROAD MED
340002520OtherPALMETTO GBA/RAILROAD MED
C08517Medicare UPIN
340002520OtherPALMETTO GBA/RAILROAD MED