Provider Demographics
NPI:1962493502
Name:DAUGHERTY, DANIEL REIF (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:REIF
Last Name:DAUGHERTY
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 1:2312 NORTHLAKE CT NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-2224
Mailing Address - Country:US
Mailing Address - Phone:419-651-9203
Mailing Address - Fax:770-822-3032
Practice Address - Street 1:555 OLD NORCROSS RD STE 100
Practice Address - Street 2:CLEAR CHOICE FAMILY MEDICINE
Practice Address - City:LAWRENCEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30046-8703
Practice Address - Country:US
Practice Address - Phone:770-822-3031
Practice Address - Fax:770-822-3032
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2016-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75441207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA9308173Medicare PIN
OHA76191Medicare UPIN
OHDA4253801Medicare PIN
OH0336587Medicaid