Healthcare Provider Details

I. General information

NPI: 1942545470
Provider Name (Legal Business Name): DANIEL WAYNE NESSELROADE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2012
Last Update Date: 10/09/2024
Certification Date: 10/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 E HIGH ST
SPRINGFIELD OH
45505-1225
US

IV. Provider business mailing address

1821 E HIGH ST
SPRINGFIELD OH
45505-1225
US

V. Phone/Fax

Practice location:
  • Phone: 937-323-7340
  • Fax: 937-323-3363
Mailing address:
  • Phone: 937-323-7340
  • Fax: 937-323-3363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number35072374
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: