Provider Demographics
NPI:1669461679
Name:SUMROK, DANIEL DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:DAVID
Last Name:SUMROK
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 1:1894 CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:MC KENZIE
Mailing Address - State:TN
Mailing Address - Zip Code:38201-2206
Mailing Address - Country:US
Mailing Address - Phone:731-352-0603
Mailing Address - Fax:731-352-0185
Practice Address - Street 1:1894 CEDAR ST
Practice Address - Street 2:1301 PRIMACY PARKWAY
Practice Address - City:MC KENZIE
Practice Address - State:TN
Practice Address - Zip Code:38201-2206
Practice Address - Country:US
Practice Address - Phone:731-352-0603
Practice Address - Fax:731-352-0185
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-21
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN218602084A0401X
TNMD0000021860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR207113001Medicaid
TN3063617Medicaid
MS03488833Medicaid