Provider Demographics
NPI:1588664106
Name:HEITHOLD, DANIEL LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:LEE
Last Name:HEITHOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:7305 JARNIGAN ROAD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421
Mailing Address - Country:US
Mailing Address - Phone:423-495-4349
Mailing Address - Fax:423-495-4934
Practice Address - Street 1:721 GLENWOOD DRIVE
Practice Address - Street 2:SUITE W-462
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421
Practice Address - Country:US
Practice Address - Phone:423-362-4554
Practice Address - Fax:423-362-4550
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2018-08-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA43386208600000X
GA043386208600000X
TN30153208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3824599OtherMEDICARE
GA000796595CMedicaid
GAGRP7585Medicare ID - Type UnspecifiedGROUP #
GA000796595CMedicaid
G67986Medicare UPIN