Provider Demographics
NPI:1760454706
Name:CRONK, DANIEL ROBERT JR (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:ROBERT
Last Name:CRONK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:DANIEL
Other - Middle Name:ROBERT
Other - Last Name:CRONK
Other - Suffix:JR
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:975 E. THIRD STREET
Mailing Address - Street 2:ATTN: PROVIDER ENROLLMENT
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403
Mailing Address - Country:US
Mailing Address - Phone:423-778-2906
Mailing Address - Fax:423-778-9497
Practice Address - Street 1:979 E. THIRD STREET
Practice Address - Street 2:SUITE #C-620
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403
Practice Address - Country:US
Practice Address - Phone:423-778-2906
Practice Address - Fax:423-778-9497
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN55484208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10026135100Medicaid
IA1760454706Medicaid
NE10025724800Medicaid
IA1760454706Medicaid