Provider Demographics
NPI:1508814211
Name:DEIGHTON, DANIEL A (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:A
Last Name:DEIGHTON
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:PO BOX 7567
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31095-7567
Mailing Address - Country:US
Mailing Address - Phone:478-293-1580
Mailing Address - Fax:478-293-1583
Practice Address - Street 1:233 N HOUSTON RD
Practice Address - Street 2:SUITE 140-F
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3074
Practice Address - Country:US
Practice Address - Phone:478-293-1580
Practice Address - Fax:478-293-1583
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA040361208600000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000670612CMedicaid
GA34BDDWV01Medicare ID - Type Unspecified
E80827Medicare UPIN