Provider Demographics
NPI:1972572246
Name:ETTEDGUI, DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:ETTEDGUI
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 1:7284 W PALMETTO PARK RD
Mailing Address - Street 2:SUITE 105S
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33433-3406
Mailing Address - Country:US
Mailing Address - Phone:561-912-9580
Mailing Address - Fax:561-912-9506
Practice Address - Street 1:7284 W PALMETTO PARK RD
Practice Address - Street 2:SUITE 105S
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33433-3406
Practice Address - Country:US
Practice Address - Phone:561-912-9580
Practice Address - Fax:561-912-9506
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-17
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS-6221208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK7441Medicare PIN
FLF25833Medicare UPIN
FLDG9168Medicare PIN