=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043273402
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DANIEL J ULICNY
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2006
-----------------------------------------------------
Last Update Date | 03/31/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 HEALTHY WAY
-----------------------------------------------------
City | OCEANSIDE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11572
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-632-4194
-----------------------------------------------------
Fax | 516-632-4195
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3998 FAIR RIDGE DR SUITE 300
-----------------------------------------------------
City | FAIRFAX
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 22033-2921
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 703-295-9360
-----------------------------------------------------
Fax | 703-766-9725
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207L00000X
-----------------------------------------------------
Taxonomy Name | Anesthesiology Physician
-----------------------------------------------------
License Number | 188750
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------