Provider Demographics
NPI:1932167616
Name:GORAN, DANIEL D (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:D
Last Name:GORAN
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 1:1261 UNIVERSITY DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-5586
Mailing Address - Country:US
Mailing Address - Phone:618-692-6718
Mailing Address - Fax:618-692-9558
Practice Address - Street 1:1261 UNIVERSITY DR
Practice Address - Street 2:SUITE D
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-5586
Practice Address - Country:US
Practice Address - Phone:618-692-6718
Practice Address - Fax:618-692-9558
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036077549174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE20207Medicare UPIN
IL799840Medicare ID - Type Unspecified