Provider Demographics
NPI:1922134287
Name:FENNELL, DAN F (MD)
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:F
Last Name:FENNELL
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 1:2620 EAST BARNETT RD
Mailing Address - Street 2:SUITE H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8383
Mailing Address - Country:US
Mailing Address - Phone:541-789-5250
Mailing Address - Fax:541-789-5538
Practice Address - Street 1:555 BLACK OAK DR
Practice Address - Street 2:SUITE 300
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-8447
Practice Address - Country:US
Practice Address - Phone:541-494-2000
Practice Address - Fax:541-494-2002
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2013-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORMD16604207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR009634Medicaid
ORD24357Medicare UPIN
OR0000WCJGJMedicare ID - Type UnspecifiedMEDICARE GROUP #