Provider Demographics
NPI:1457619686
Name:MIZRAHI, DANIEL
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:MIZRAHI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 11TH ST
Mailing Address - Street 2:THOMAS JEFFERSON UNIVERSITY HOSPITAL
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4824
Mailing Address - Country:US
Mailing Address - Phone:215-955-6000
Mailing Address - Fax:
Practice Address - Street 1:44 E JIMMIE LEEDS RD STE 101
Practice Address - Street 2:
Practice Address - City:GALLOWAY
Practice Address - State:NJ
Practice Address - Zip Code:08205-9599
Practice Address - Country:US
Practice Address - Phone:609-677-9729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-25
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA102147002085R0202X
PAMT201066390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ678486OtherMEDICARE OF NJ
NJ0619523Medicaid