Provider Demographics
NPI:1174511562
Name:MCDANIEL, WILLIAM L JR (MD)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:L
Last Name:MCDANIEL
Suffix:JR
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 1:1243 BROADRICK DR
Mailing Address - Street 2:
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2800
Mailing Address - Country:US
Mailing Address - Phone:706-529-1765
Mailing Address - Fax:706-529-7438
Practice Address - Street 1:1243 BROADRICK DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2800
Practice Address - Country:US
Practice Address - Phone:706-529-1765
Practice Address - Fax:706-529-7438
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11409207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000095972DMedicaid
AM5759747OtherDEA
101931140AMedicare ID - Type Unspecified
GA000095972DMedicaid