Provider Demographics
NPI:1730642802
Name:BLY BRACK, DANIELLE ANN (MD)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:ANN
Last Name:BLY BRACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:ANN
Other - Last Name:BLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5757 PARK CENTER CT.
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615
Mailing Address - Country:US
Mailing Address - Phone:419-474-4064
Mailing Address - Fax:419-472-2772
Practice Address - Street 1:5757 PARK CENTER CT.
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615
Practice Address - Country:US
Practice Address - Phone:419-474-4064
Practice Address - Fax:419-472-2772
Is Sole Proprietor?:No
Enumeration Date:2019-04-07
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43015113632085R0202X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program