Healthcare Provider Details

I. General information

NPI: 1720425424
Provider Name (Legal Business Name): DANIEL ENSLEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2013
Last Update Date: 12/27/2023
Certification Date: 12/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

340 BOATNER RD
EGLIN AFB FL
32542-1391
US

IV. Provider business mailing address

340 BOATNER RD
EGLIN AFB FL
32542-1391
US

V. Phone/Fax

Practice location:
  • Phone: 850-883-8347
  • Fax:
Mailing address:
  • Phone: 850-883-8347
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR74100
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number0101257215
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: