Provider Demographics
NPI:1205071552
Name:MAXWELL, DANIEL LEE
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:LEE
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CLINIC AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CARROLLTON
Mailing Address - State:GA
Mailing Address - Zip Code:30117-4402
Mailing Address - Country:US
Mailing Address - Phone:770-834-0873
Mailing Address - Fax:770-834-6118
Practice Address - Street 1:150 CLINIC AVE STE 101
Practice Address - Street 2:
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-4402
Practice Address - Country:US
Practice Address - Phone:770-834-0873
Practice Address - Fax:770-834-6118
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA080787207XX0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle Surgery