Provider Demographics
NPI:1629076849
Name:MCCORMACK, DANIEL R (DO)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:R
Last Name:MCCORMACK
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 1:485 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5005
Mailing Address - Country:US
Mailing Address - Phone:812-334-1198
Mailing Address - Fax:812-334-1199
Practice Address - Street 1:485 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5005
Practice Address - Country:US
Practice Address - Phone:812-334-1198
Practice Address - Fax:812-334-1199
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2012-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001722A207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200091640Medicaid
IN548000AMedicare ID - Type Unspecified
IN200091640Medicaid