Provider Demographics
NPI:1043264393
Name:DANIELS, TYRONE L (MD)
Entity Type:Individual
Prefix:
First Name:TYRONE
Middle Name:L
Last Name:DANIELS
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 1:8019 DIXIE HWY STE 101
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40258-1303
Mailing Address - Country:US
Mailing Address - Phone:502-333-3121
Mailing Address - Fax:502-531-9538
Practice Address - Street 1:8019 DIXIE HWY STE 101
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40258-1303
Practice Address - Country:US
Practice Address - Phone:502-333-3121
Practice Address - Fax:502-531-9538
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV14818207RC0000X
KY32841207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00837112OtherMEDICARE RAILROAD
KY64328412Medicaid
WV0070798000Medicaid
KY0921301Medicare ID - Type Unspecified
P00837112OtherMEDICARE RAILROAD
KY64328412Medicaid