Provider Demographics
NPI:1528035607
Name:MCDANIEL, JEANETTE R (MD)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:R
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1829 REISTERSTOWN ROAD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208
Mailing Address - Country:US
Mailing Address - Phone:410-602-9850
Mailing Address - Fax:410-602-9857
Practice Address - Street 1:1829 REISTERSTOWN ROAD
Practice Address - Street 2:SUITE 205
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208
Practice Address - Country:US
Practice Address - Phone:410-602-9850
Practice Address - Fax:410-602-9857
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0034935208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD48402160Medicaid
MD48402160Medicaid
E18261Medicare UPIN