Provider Demographics
NPI:1134393796
Name:KETTERER, DANIEL CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:CHRISTOPHER
Last Name:KETTERER
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 1:1960 RIVERSIDE PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LAWRENCEVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30043-5945
Mailing Address - Country:US
Mailing Address - Phone:770-995-0466
Mailing Address - Fax:
Practice Address - Street 1:1960 RIVERSIDE PKWY STE 101
Practice Address - Street 2:
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30043-5945
Practice Address - Country:US
Practice Address - Phone:770-995-0466
Practice Address - Fax:770-995-0472
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-15
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1371043207RI0200X
GA070952207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease