Provider Demographics
NPI:1447218862
Name:DANIEL, GARY ANTHONY (MD)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:ANTHONY
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 1:2064 VINEVILLE AVENUE
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31204-3140
Mailing Address - Country:US
Mailing Address - Phone:478-743-1478
Mailing Address - Fax:478-746-8536
Practice Address - Street 1:2064 VINEVILLE AVENUE
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-3140
Practice Address - Country:US
Practice Address - Phone:478-743-1478
Practice Address - Fax:478-746-8536
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.200465207R00000X
GA046752207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1777943Medicaid
LA4J886Medicare ID - Type Unspecified
LA1777943Medicaid