Provider Demographics
NPI:1790066108
Name:PEDERSEN, DANIEL A (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:A
Last Name:PEDERSEN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450E CHESTNUT AVE 3D
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08361-8469
Mailing Address - Country:US
Mailing Address - Phone:856-692-0050
Mailing Address - Fax:856-692-0081
Practice Address - Street 1:200 SCHUYLKILL MEDICAL PLZ
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-3660
Practice Address - Country:US
Practice Address - Phone:570-621-9270
Practice Address - Fax:570-621-9271
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-30
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
PAOS021569207Q00000X
NJ25MB09405100207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program