Provider Demographics
NPI:1851373591
Name:DE JESUS, DANIEL (PAC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:134 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-2507
Mailing Address - Country:US
Mailing Address - Phone:203-756-8911
Mailing Address - Fax:203-574-0548
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 200
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-289-3375
Practice Address - Fax:860-783-5733
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT000848363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P35061Medicare UPIN
CTD400000707Medicare PIN