Healthcare Provider Details

I. General information

NPI: 1487648184
Provider Name (Legal Business Name): DANIEL A BOLL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2005
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 W EDISON RD SUITE 110
MISHAWAKA IN
46545-2784
US

IV. Provider business mailing address

620 W EDISON RD SUITE 110
MISHAWAKA IN
46545-2784
US

V. Phone/Fax

Practice location:
  • Phone: 574-258-1100
  • Fax: 574-258-1101
Mailing address:
  • Phone: 574-258-1100
  • Fax: 574-258-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number01035496
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number01035496
License Number StateIN
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number01035496
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number01035496
License Number StateIN
# 5
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number01035496
License Number StateIN
# 6
Primary TaxonomyN
Taxonomy Code2085R0203X
TaxonomyTherapeutic Radiology Physician
License Number01035496
License Number StateIN
# 7
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number01035496
License Number StateIN
# 8
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number01035496
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: