Provider Demographics
NPI:1760424667
Name:MCDANIEL, CONNIE MEEKS (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MEEKS
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:ANNELLE
Other - Last Name:MEEKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3828 S CULBERHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72404-9067
Mailing Address - Country:US
Mailing Address - Phone:870-972-6295
Mailing Address - Fax:
Practice Address - Street 1:707 E MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3103
Practice Address - Country:US
Practice Address - Phone:870-974-5790
Practice Address - Fax:870-974-5713
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-3870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARD04575Medicare UPIN
AR51944Medicare ID - Type UnspecifiedTERMINATED