Provider Demographics
NPI:1144539412
Name:KETTLIE JOSEPH DANIELS, MD, INC.
Entity type:Organization
Organization Name:KETTLIE JOSEPH DANIELS, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KETTLIE
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:419-842-0140
Mailing Address - Street 1:980 S BYRNE RD
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43609-1010
Mailing Address - Country:US
Mailing Address - Phone:419-842-0140
Mailing Address - Fax:419-842-0142
Practice Address - Street 1:980 S BYRNE RD
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43609-1010
Practice Address - Country:US
Practice Address - Phone:419-842-0140
Practice Address - Fax:419-842-0142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350576212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty