Provider Demographics
NPI:1720037252
Name:DANIELSON, KENNETH S (MD)
Entity Type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:S
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 1:1290 HOSPITAL DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-9205
Mailing Address - Country:US
Mailing Address - Phone:802-748-2984
Mailing Address - Fax:
Practice Address - Street 1:1290 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-9205
Practice Address - Country:US
Practice Address - Phone:802-748-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0420006525207R00000X
NH5957208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3080079Medicaid
VT0005741Medicaid
VT0005741Medicaid
B85747Medicare UPIN
NH3080079Medicaid
VTVT574102Medicare PIN