Provider Demographics
NPI:1275571846
Name:DANIEL, ROOSEVELT G (MD)
Entity Type:Individual
Prefix:
First Name:ROOSEVELT
Middle Name:G
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 1:2749 CARRIAGE LN
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29505-6498
Mailing Address - Country:US
Mailing Address - Phone:843-673-7046
Mailing Address - Fax:
Practice Address - Street 1:545 SUMTER HWY
Practice Address - Street 2:
Practice Address - City:BISHOPVILLE
Practice Address - State:SC
Practice Address - Zip Code:29010-7601
Practice Address - Country:US
Practice Address - Phone:803-484-5317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27716207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00906560OtherRAILROAD MEDICARE PTAN
SCAA08841850Medicare PIN
SCP00906560OtherRAILROAD MEDICARE PTAN
SCAA75064784Medicare PIN