Provider Demographics
NPI:1073580445
Name:MCDANIEL, JOHN GORDON (OD, MLHR)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:GORDON
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:OD, MLHR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12311 PINE BLUFFS WAY # 108
Mailing Address - Street 2:
Mailing Address - City:PARKER
Mailing Address - State:CO
Mailing Address - Zip Code:80134-4339
Mailing Address - Country:US
Mailing Address - Phone:303-805-7300
Mailing Address - Fax:888-317-1023
Practice Address - Street 1:12311 PINE BLUFFS WAY # 108
Practice Address - Street 2:
Practice Address - City:PARKER
Practice Address - State:CO
Practice Address - Zip Code:80134-4339
Practice Address - Country:US
Practice Address - Phone:303-805-7300
Practice Address - Fax:888-317-1023
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2702152W00000X
WI2989-035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO38646700Medicaid
CO38646700Medicaid