Healthcare Provider Details

I. General information

NPI: 1003892357
Provider Name (Legal Business Name): DANIEL L VENARSKE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 LAKELAND DR. SUITE 101
JACKSON MS
39216
US

IV. Provider business mailing address

1513 LAKELAND DR., SUITE 101
JACKSON MS
39216
US

V. Phone/Fax

Practice location:
  • Phone: 601-354-4836
  • Fax: 601-354-2619
Mailing address:
  • Phone: 601-354-4836
  • Fax: 601-354-2619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number16963
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: