Provider Demographics
NPI:1982281028
Name:BAUX, DANIEL IVO
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:IVO
Last Name:BAUX
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 1:3436 COURTENAY CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-2614
Mailing Address - Country:US
Mailing Address - Phone:561-699-1187
Mailing Address - Fax:
Practice Address - Street 1:4190 CITY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-1626
Practice Address - Country:US
Practice Address - Phone:561-699-1187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-25
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program