Healthcare Provider Details

I. General information

NPI: 1154396802
Provider Name (Legal Business Name): DANIEL J MAYDONOVITCH DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 01/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 N WALNUT ST
BOYERTOWN PA
19512-1467
US

IV. Provider business mailing address

23 N WALNUT ST
BOYERTOWN PA
19512-1467
US

V. Phone/Fax

Practice location:
  • Phone: 610-367-2259
  • Fax: 610-367-0505
Mailing address:
  • Phone: 610-367-2259
  • Fax: 610-367-0505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS007688L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: