Healthcare Provider Details

I. General information

NPI: 1871986992
Provider Name (Legal Business Name): DENNIS DAAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2015
Last Update Date: 03/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6177 SUN BLVD
ST PETERSBURG FL
33715-1169
US

IV. Provider business mailing address

6177 SUN BLVD
ST PETERSBURG FL
33715-1169
US

V. Phone/Fax

Practice location:
  • Phone: 727-641-7921
  • Fax:
Mailing address:
  • Phone: 727-641-7921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberME15777
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: