Provider Demographics
NPI:1790770329
Name:DANIEL, JEROME M (MD)
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:M
Last Name:DANIEL
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 1:1441 JOHNSTON WILLIS DR
Mailing Address - Street 2:
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23235-4730
Mailing Address - Country:US
Mailing Address - Phone:804-320-1333
Mailing Address - Fax:804-320-5606
Practice Address - Street 1:1441 JOHNSTON WILLIS DR
Practice Address - Street 2:
Practice Address - City:NORTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23235-4730
Practice Address - Country:US
Practice Address - Phone:804-320-1333
Practice Address - Fax:804-320-5606
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028297207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5609771Medicaid
080063592OtherRR MEDICARE