Provider Demographics
NPI:1033170634
Name:FANG, DANIEL T (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:FANG
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 1:3811 E BELL RD STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2160
Mailing Address - Country:US
Mailing Address - Phone:480-454-7350
Mailing Address - Fax:602-482-2874
Practice Address - Street 1:3811 E BELL RD STE 300
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2160
Practice Address - Country:US
Practice Address - Phone:480-454-7350
Practice Address - Fax:602-482-2874
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT267271-1205208600000X
AZ30861208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ727513OtherAHCCCS
AZ727513OtherAHCCCS
AZF69062Medicare UPIN