Provider Demographics
NPI:1093900177
Name:JOHN G MCDANIEL, OD LLC
Entity Type:Organization
Organization Name:JOHN G MCDANIEL, OD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:GORDON
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD, MLHR
Authorized Official - Phone:262-751-2834
Mailing Address - Street 1:9777 WIMBLEDON CT
Mailing Address - Street 2:
Mailing Address - City:HIGHLANDS RANCH
Mailing Address - State:CO
Mailing Address - Zip Code:80126-3051
Mailing Address - Country:US
Mailing Address - Phone:262-751-2834
Mailing Address - Fax:888-317-1023
Practice Address - Street 1:9777 WIMBLEDON CT
Practice Address - Street 2:
Practice Address - City:HIGHLANDS RANCH
Practice Address - State:CO
Practice Address - Zip Code:80126-3051
Practice Address - Country:US
Practice Address - Phone:262-751-2834
Practice Address - Fax:888-317-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2702152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000047875Medicare PIN
V01490Medicare UPIN