Provider Demographics
NPI:1760610265
Name:MCDANIEL, DENVER JOSEPH (OD)
Entity Type:Individual
Prefix:DR
First Name:DENVER
Middle Name:JOSEPH
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:744 E 3RD ST
Mailing Address - Street 2:ROOM 128
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47405-3603
Mailing Address - Country:US
Mailing Address - Phone:812-856-5602
Mailing Address - Fax:812-855-6116
Practice Address - Street 1:4719 W STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47404-9518
Practice Address - Country:US
Practice Address - Phone:812-876-2020
Practice Address - Fax:812-935-2020
Is Sole Proprietor?:No
Enumeration Date:2009-06-24
Last Update Date:2023-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901004616152W00000X
IN18003600152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200945160Medicaid
IN825700VVVMedicare PIN
IN200945160Medicaid
MI0C97655075Medicare PIN
IN544150MMMMMedicare PIN
IN546000RRRMedicare PIN