Provider Demographics
NPI:1487628905
Name:IVAN, DANIEL L (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:IVAN
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 1:6431 FANNIN ST
Mailing Address - Street 2:JJL 495
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1501
Mailing Address - Country:US
Mailing Address - Phone:713-500-5666
Mailing Address - Fax:713-500-0527
Practice Address - Street 1:6431 FANNIN ST
Practice Address - Street 2:JJL 495
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-1501
Practice Address - Country:US
Practice Address - Phone:713-500-5666
Practice Address - Fax:713-500-0527
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN6380208000000X
MI4301078858208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4609698Medicaid
MIE96012011Medicare PIN
I09811Medicare UPIN