Basic Information
| Provider Information | |||||||||
| NPI: | 1235164054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAINES | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | T | ||||||||
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| Credential: | D.P.M. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 225 CROSSLAKE DR | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477158198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124771558 | ||||||||
| FaxNumber: | 8124884669 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 CROSSLAKE DR | ||||||||
| Address2: | |||||||||
| City: | EVANSVILLE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 477158198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8124771558 | ||||||||
| FaxNumber: | 8124884669 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 03/30/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 587 | AZ | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | 07001080A | IN | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 815615 | 05 | AZ | MEDICAID |