Provider Demographics
NPI:1023692183
Name:MCDANIEL, JACK MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MICHAEL
Last Name:MCDANIEL
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 1:12415 N INTERSTATE 35
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-1326
Mailing Address - Country:US
Mailing Address - Phone:737-205-1270
Mailing Address - Fax:
Practice Address - Street 1:12415 N INTERSTATE 35
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-1326
Practice Address - Country:US
Practice Address - Phone:737-205-1270
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXBP10076142207Q00000X
TXU0805207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine