Provider Demographics
NPI:1457498107
Name:T. GERALD O'DANIEL M.D., PLLC
Entity Type:Organization
Organization Name:T. GERALD O'DANIEL M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:T.
Authorized Official - Middle Name:GERALD
Authorized Official - Last Name:O'DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PLLC
Authorized Official - Phone:502-584-1109
Mailing Address - Street 1:222 S 1ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1350
Mailing Address - Country:US
Mailing Address - Phone:502-584-1109
Mailing Address - Fax:502-589-6882
Practice Address - Street 1:222 S 1ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1350
Practice Address - Country:US
Practice Address - Phone:502-584-1109
Practice Address - Fax:502-589-6882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY240702086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYKY1118OtherHEALTHNET
KY1058697OtherPASSPORT PIN
KY000000219660OtherANTHEM PIN
KY002OtherCIGNA
IN100033340AMedicaid
KY667357OtherHEALTHLINK
KY64240708Medicaid
KYKY0057799OtherTRICARE
KY240007956Medicare ID - Type UnspecifiedRAILROAD MEDICARE ID
KY1918001Medicare PIN
KY64240708Medicaid