Provider Demographics
NPI:1609936004
Name:COVERDELL, DANIEL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:JOHN
Last Name:COVERDELL
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 1:15217 DARBY RD
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-9211
Mailing Address - Country:US
Mailing Address - Phone:907-622-5584
Mailing Address - Fax:
Practice Address - Street 1:11470 BUSINESS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:EAGLE RIVER
Practice Address - State:AK
Practice Address - Zip Code:99577-7721
Practice Address - Country:US
Practice Address - Phone:907-622-4325
Practice Address - Fax:907-622-4326
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK4780174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD63211Medicaid
AKMD6231Medicaid
AK4780OtherSTATE LICENSE #
AKMD63211Medicaid
AK15482Medicare ID - Type UnspecifiedMEDICARE