Provider Demographics
NPI:1356636575
Name:MCDANIEL, BRENT JACKSON (DO)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:JACKSON
Last Name:MCDANIEL
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 1:309 HIGHWAY 361
Mailing Address - Street 2:
Mailing Address - City:CRANE
Mailing Address - State:IN
Mailing Address - Zip Code:47522-9731
Mailing Address - Country:US
Mailing Address - Phone:270-314-4401
Mailing Address - Fax:
Practice Address - Street 1:1985 E FREEDOM DR
Practice Address - Street 2:
Practice Address - City:NEWBERRY
Practice Address - State:IN
Practice Address - Zip Code:47449-7125
Practice Address - Country:US
Practice Address - Phone:270-314-4401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-15
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02004071A207L00000X, 208D00000X
KY05348207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology