Basic Information
| Provider Information | |||||||||
| NPI: | 1790066108 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PEDERSEN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450E CHESTNUT AVE 3D | ||||||||
| Address2: | |||||||||
| City: | VINELAND | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 083618469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8566920050 | ||||||||
| FaxNumber: | 8566920081 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 SCHUYLKILL MEDICAL PLZ | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706219270 | ||||||||
| FaxNumber: | 5706219271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2011 | ||||||||
| LastUpdateDate: | 11/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25MB09405100 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | OS021569 | PA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.