Healthcare Provider Details

I. General information

NPI: 1265516611
Provider Name (Legal Business Name): DANIEL ETTEDGUI, D.O. PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 04/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1905 CLINT MOORE ROAD SUITE 308
BOCA RATON FL
33496-2658
US

IV. Provider business mailing address

1905 CLINT MOORE ROAD SUITE 308
BOCA RATON FL
33496
US

V. Phone/Fax

Practice location:
  • Phone: 561-912-9580
  • Fax: 561-912-9506
Mailing address:
  • Phone: 561-912-9580
  • Fax: 561-912-9506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS-6221
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS6221
License Number StateFL

VIII. Authorized Official

Name: MRS. FLORI F MCGINTY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 561-912-9580