Provider Demographics
NPI:1467573618
Name:DANIEL, DERWENT O (NP)
Entity Type:Individual
Prefix:
First Name:DERWENT
Middle Name:O
Last Name:DANIEL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2731 MLK JR BLVD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-5235
Mailing Address - Country:US
Mailing Address - Phone:205-349-3250
Mailing Address - Fax:205-345-3993
Practice Address - Street 1:345 MAGNOLIA STREET
Practice Address - Street 2:
Practice Address - City:WEST BLOCTON
Practice Address - State:AL
Practice Address - Zip Code:35184
Practice Address - Country:US
Practice Address - Phone:205-938-9508
Practice Address - Fax:205-938-9550
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology