Provider Demographics
NPI:1760531826
Name:KVESELIS, DANIEL A (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:A
Last Name:KVESELIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:725 IRVING AVE
Mailing Address - Street 2:SUITE 804
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-1603
Mailing Address - Country:US
Mailing Address - Phone:315-214-7700
Mailing Address - Fax:315-214-7701
Practice Address - Street 1:725 IRVING AVE
Practice Address - Street 2:SUITE 804
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-1603
Practice Address - Country:US
Practice Address - Phone:315-214-7700
Practice Address - Fax:315-214-7701
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1744622080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01115902Medicaid
NY01115902Medicaid
NYCC6764Medicare ID - Type Unspecified