Provider Demographics
NPI:1750319323
Name:SEVERA, DAN G (MD)
Entity Type:Individual
Prefix:MR
First Name:DAN
Middle Name:G
Last Name:SEVERA
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:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-2111
Mailing Address - Fax:
Practice Address - Street 1:208 HALEY RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TX
Practice Address - Zip Code:78636-4617
Practice Address - Country:US
Practice Address - Phone:830-868-9500
Practice Address - Fax:830-868-4606
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0425270207Q00000X
TXS6935207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSA14584Medicare UPIN
KS101240Medicare ID - Type Unspecified