Healthcare Provider Details

I. General information

NPI: 1740268077
Provider Name (Legal Business Name): DANIEL JAY PODBERESKY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2006
Last Update Date: 09/15/2020
Certification Date: 09/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6535 NEMOURS PKWY
ORLANDO FL
32827-7884
US

IV. Provider business mailing address

PO BOX 191
ROCKLAND DE
19732-0191
US

V. Phone/Fax

Practice location:
  • Phone: 407-567-4000
  • Fax: 407-567-5924
Mailing address:
  • Phone: 302-651-6212
  • Fax: 302-651-4945

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberC10011071
License Number StateDE
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberL9429
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberME120711
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: