Healthcare Provider Details

I. General information

NPI: 1144394388
Provider Name (Legal Business Name): BYRON D. DANIELSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 ELM ST N
FARGO ND
58102-2417
US

IV. Provider business mailing address

2578 WILLOW RD N
FARGO ND
58102-2161
US

V. Phone/Fax

Practice location:
  • Phone: 701-239-3700
  • Fax:
Mailing address:
  • Phone: 701-237-5525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number3768
License Number StateND

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier12375
Identifier TypeMEDICAID
Identifier StateND
Identifier Issuer
# 2
Identifier2064787
Identifier TypeMEDICAID
Identifier StateMN
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: