Provider Demographics
NPI:1740385541
Name:AVERY, DANIEL BEN (MD)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:BEN
Last Name:AVERY
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 1:3400C OLD MILTON PKWY STE 270
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30005-4438
Mailing Address - Country:US
Mailing Address - Phone:770-442-1911
Mailing Address - Fax:478-246-6155
Practice Address - Street 1:230 INDUSTRIAL BLVD STE D
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:GA
Practice Address - Zip Code:31021-2904
Practice Address - Country:US
Practice Address - Phone:478-272-1366
Practice Address - Fax:478-275-2322
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA058439207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA526388566CMedicaid
GA202I114841Medicare PIN
GA526388566CMedicaid