Healthcare Provider Details

I. General information

NPI: 1962898031
Provider Name (Legal Business Name): DANIEL COLON-CONDE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/15/2015
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 PHILIP BLVD STE 140
LAWRENCEVILLE GA
30046-8768
US

IV. Provider business mailing address

455 PHILIP BLVD STE 140
LAWRENCEVILLE GA
30046-8768
US

V. Phone/Fax

Practice location:
  • Phone: 770-962-3642
  • Fax: 770-962-3643
Mailing address:
  • Phone: 770-962-3642
  • Fax: 770-962-3643

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberME148033
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number90526
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: