Provider Demographics
NPI:1790084168
Name:DODARD, DANIEL MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:MARTIN
Last Name:DODARD
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 1:2470 BLOOMINGDALE AVE STE 123
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-6403
Mailing Address - Country:US
Mailing Address - Phone:813-655-8096
Mailing Address - Fax:813-684-1610
Practice Address - Street 1:2470 BLOOMINGDALE AVE STE 123
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-6403
Practice Address - Country:US
Practice Address - Phone:813-655-8096
Practice Address - Fax:813-684-1610
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2022-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 108955207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004757000Medicaid
FL0047570-00Medicaid
FLFK977YMedicare PIN