Provider Demographics
NPI:1710167168
Name:DANIELS, CHARLES SHANE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:SHANE
Last Name:DANIELS
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:PO BOX 63082
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-2808
Mailing Address - Country:US
Mailing Address - Phone:919-785-3400
Mailing Address - Fax:919-783-7778
Practice Address - Street 1:4130 OLEANDER DR STE 100
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6844
Practice Address - Country:US
Practice Address - Phone:910-338-3494
Practice Address - Fax:910-338-0860
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2023-01908207LP2900X, 208VP0000X, 208VP0014X
CAA94985208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine