Provider Demographics
NPI:1023002458
Name:DEJARNATT, DANIEL (OD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:
Last Name:DEJARNATT
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 THORNTON TAYLOR PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-3655
Mailing Address - Country:US
Mailing Address - Phone:931-433-3084
Mailing Address - Fax:931-433-4188
Practice Address - Street 1:2300 THORNTON TAYLOR PKWY STE C
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-3655
Practice Address - Country:US
Practice Address - Phone:931-433-3084
Practice Address - Fax:931-433-4188
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2014-05-29
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-04-04
Provider Licenses
StateLicense IDTaxonomies
TN1046152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3595901Medicaid
TN71288OtherBCBS
TN3595901Medicaid
T61274Medicare UPIN