Provider Demographics
NPI:1205254075
Name:LAX, DANIEL BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:BENJAMIN
Last Name:LAX
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 1:67 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:DERBY
Mailing Address - State:CT
Mailing Address - Zip Code:06418-1328
Mailing Address - Country:US
Mailing Address - Phone:203-732-1256
Mailing Address - Fax:203-732-1539
Practice Address - Street 1:300 SEYMOUR AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1343
Practice Address - Country:US
Practice Address - Phone:203-516-5303
Practice Address - Fax:203-732-8136
Is Sole Proprietor?:No
Enumeration Date:2014-03-31
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY293023-1207V00000X
CT64021207V00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program