Provider Demographics
NPI:1629168679
Name:MCEVOY, DANYEL BOURGEOIS (MD)
Entity Type:Individual
Prefix:DR
First Name:DANYEL
Middle Name:BOURGEOIS
Last Name:MCEVOY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TRACIE
Other - Middle Name:DANYEL
Other - Last Name:BOURGEOIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:
Practice Address - Street 1:4450 LEEDS PL W STE A
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8405
Practice Address - Country:US
Practice Address - Phone:843-763-2611
Practice Address - Fax:843-852-4099
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25287207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC252871Medicaid