Provider Demographics
NPI:1134230311
Name:MCDANIEL, MARK ELLIOTT (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ELLIOTT
Last Name:MCDANIEL
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4190
Mailing Address - Street 2:
Mailing Address - City:BARBOURSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25504-4190
Mailing Address - Country:US
Mailing Address - Phone:304-399-4405
Mailing Address - Fax:304-399-2526
Practice Address - Street 1:201 22ND ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-7803
Practice Address - Country:US
Practice Address - Phone:866-233-1955
Practice Address - Fax:304-523-7738
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS10096207Q00000X
OH34.010454207Q00000X
NC2012-01177207Q00000X
WV1980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2004366000Medicaid
OHP01135827OtherMEDICARE RAILROAD - MHCPI
OH0066990Medicaid
FLP00609571OtherMCR RR
FL30257Medicaid
OH0066990Medicaid
FLP00609571OtherMCR RR
OH2004366000Medicaid