Provider Demographics
NPI:1174594279
Name:DUKE, DANIELLA (MD)
Entity type:Individual
Prefix:DR
First Name:DANIELLA
Middle Name:
Last Name:DUKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-2636
Mailing Address - Country:US
Mailing Address - Phone:860-245-0000
Mailing Address - Fax:860-245-0610
Practice Address - Street 1:55 WILLOW ST
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2636
Practice Address - Country:US
Practice Address - Phone:860-245-0000
Practice Address - Fax:860-245-0610
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-28
Last Update Date:2011-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035895207N00000X
RIMD10187207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT070000403Medicare ID - Type Unspecified
C02638Medicare PIN
CTG45797Medicare UPIN