Provider Demographics
NPI:1609616259
Name:LARGE, ISRAEL DANIEL (MD)
Entity type:Individual
Prefix:
First Name:ISRAEL
Middle Name:DANIEL
Last Name:LARGE
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 1:1501 E WHITTON AVE APT 302
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5180
Mailing Address - Country:US
Mailing Address - Phone:915-867-0499
Mailing Address - Fax:
Practice Address - Street 1:13013 FULLER AVE STE A
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-2687
Practice Address - Country:US
Practice Address - Phone:915-867-0499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-30
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program