Provider Demographics
NPI:1508188145
Name:DANIELS, WAYNE WORTH (DO)
Entity Type:Individual
Prefix:DR
First Name:WAYNE
Middle Name:WORTH
Last Name:DANIELS
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 1:1655 ROBERTS BLVD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30144-3632
Mailing Address - Country:US
Mailing Address - Phone:770-419-3355
Mailing Address - Fax:
Practice Address - Street 1:1655 ROBERTS BLVD NW
Practice Address - Street 2:
Practice Address - City:KENNESAW
Practice Address - State:GA
Practice Address - Zip Code:30144-3632
Practice Address - Country:US
Practice Address - Phone:770-419-3355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA059703207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology