Provider Demographics
NPI:1255490561
Name:ALT, DANIEL BENJAMIN (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:BENJAMIN
Last Name:ALT
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 1:211 PEPPERBUSH RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-5714
Mailing Address - Country:US
Mailing Address - Phone:502-895-9983
Mailing Address - Fax:
Practice Address - Street 1:211 PEPPERBUSH RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-5714
Practice Address - Country:US
Practice Address - Phone:502-895-9983
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY18530174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYD92417Medicare UPIN