MEDICARE: DR. LISA CADOO DANIELS M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	31816	AL
2	207R00000X	Internal Medicine Physician	25MA09608400	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	511-29174	OTHER	AL	BC AND BS OF AL
3	HORIZON	OTHER	NJ	BLUECROSS
4	UHC	OTHER	NJ	UNITED HEALTHCARE
5	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
6	BCBS	OTHER	NJ	BLUE CROSS BLUE SHIELD
7	CIGNA	OTHER	NJ	CIGNA

General Provider Information

NPI Number	:	1538460498
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA CADOO DANIELS M.D.

Provider Business Mailing Address
First Line	:	66 PARK ST STE 100
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-2988
Country	:	US
Telephone Number	:	973-577-3010
Fax Number	:	973-577-3011

Provider Business Practice Location Address
First Line	:	66 PARK ST STE 100
Second Line	:
City	:	MONTCLAIR
State	:	NJ
Zip	:	07042-2988
Country	:	US
Telephone Number	:	973-577-3010
Fax Number	:	973-577-3011

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2010
Last Update Date	:	05/20/2026

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