Provider Demographics
NPI:1881181675
Name:FANOUSE, DANIEL (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:FANOUSE
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 1:46 BARTLETT AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-2462
Mailing Address - Country:US
Mailing Address - Phone:646-251-6732
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:OLD BRIDGE
Practice Address - State:NJ
Practice Address - Zip Code:08857-3012
Practice Address - Country:US
Practice Address - Phone:732-360-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-17
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MB11532600207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program