Provider Demographics
NPI:1164529640
Name:ODANIEL, MARK BARNARD (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:BARNARD
Last Name:ODANIEL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 NORTH WINSTEAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2422
Mailing Address - Country:US
Mailing Address - Phone:252-937-8222
Mailing Address - Fax:252-937-6622
Practice Address - Street 1:201 NORTH WINSTEAD
Practice Address - Street 2:SUITE A
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2422
Practice Address - Country:US
Practice Address - Phone:252-937-8222
Practice Address - Fax:252-937-6622
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-19
Last Update Date:2011-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700116174400000X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903560Medicaid
NC5903546Medicaid
NC135V6OtherBCBS NUMBER
NC89135V6Medicaid
NC5903546Medicaid
NC5903560Medicaid
NC135V6OtherBCBS NUMBER
NC89135V6Medicaid