Provider Demographics
NPI:1366600058
Name:KRAVITZ, DANIEL JAY (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAY
Last Name:KRAVITZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3173
Mailing Address - Country:US
Mailing Address - Phone:936-634-8434
Mailing Address - Fax:
Practice Address - Street 1:2 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904
Practice Address - Country:US
Practice Address - Phone:936-634-8434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN104518207W00000X
MN52275207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
MNP00954334OtherRAILROAD MEDICARE
MNENROLLEDMedicaid