Provider Demographics
NPI:1922081538
Name:FANNEY, DARYL R (MD)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:R
Last Name:FANNEY
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 1:4668 PEMBROKE BLVD
Mailing Address - Street 2:SUITE 117
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6423
Mailing Address - Country:US
Mailing Address - Phone:757-671-1144
Mailing Address - Fax:757-671-1265
Practice Address - Street 1:4668 PEMBROKE BLVD
Practice Address - Street 2:SUITE 117
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6423
Practice Address - Country:US
Practice Address - Phone:757-671-1144
Practice Address - Fax:757-671-1265
Is Sole Proprietor?:No
Enumeration Date:2005-11-29
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010455472085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890524YMedicaid
VA007213905Medicaid
VA380544OtherANTHEM BC/BS PROV#
VA007213905Medicaid
VAP00279326Medicare PIN
VA380544OtherANTHEM BC/BS PROV#
NC890524YMedicaid