Provider Demographics
NPI:1053452615
Name:DANIEL, JARROD RYAN (MD)
Entity Type:Individual
Prefix:
First Name:JARROD
Middle Name:RYAN
Last Name:DANIEL
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 1:2215 RANDOLPH ROAD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207
Mailing Address - Country:US
Mailing Address - Phone:704-372-6846
Mailing Address - Fax:704-342-0752
Practice Address - Street 1:2215 RANDOLPH ROAD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207
Practice Address - Country:US
Practice Address - Phone:704-372-6846
Practice Address - Fax:704-342-0752
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN49702208600000X
NC2013--01297208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN639138000Medicaid
MN020002381Medicare PIN
MN639138000Medicaid