Provider Demographics
NPI:1932108172
Name:DANIEL, CHARLES WILCOX (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:WILCOX
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 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0002
Mailing Address - Fax:225-767-9196
Practice Address - Street 1:12525 PERKINS RD
Practice Address - Street 2:SUITE C
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1907
Practice Address - Country:US
Practice Address - Phone:225-769-2003
Practice Address - Fax:225-767-3055
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015131208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1315541Medicaid
LAI56720Medicare UPIN
LA247662YJA2Medicare PIN
LAI56720Medicare UPIN