Basic Information
| Provider Information | |||||||||
| NPI: | 1386656213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HAMSTRA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | ALLAN | ||||||||
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| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 130 TOWN CENTER DR | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480841744 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485858265 | ||||||||
| FaxNumber: | 2485858266 | ||||||||
| Practice Location | |||||||||
| Address1: | 18181 OAKWOOD BLVD | ||||||||
| Address2: | |||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481245032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135933733 | ||||||||
| FaxNumber: | 2489825425 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 4301077751 | MI | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | Q4421 | TX | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
| ID | Type | State | Issuer | Description | 346767201 | 05 | TX | MEDICAID | P01667433 | 01 | TX | RAILROAD | OTHER | 346767202 | 05 | TX | MEDICAID |