Provider Demographics
NPI:1205267010
Name:MCDANIEL, JOE
Entity type:Individual
Prefix:
First Name:JOE
Middle Name:
Last Name:MCDANIEL
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 1:315 ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-8522
Mailing Address - Country:US
Mailing Address - Phone:918-207-9807
Mailing Address - Fax:
Practice Address - Street 1:1700 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-3340
Practice Address - Country:US
Practice Address - Phone:918-207-9807
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-03
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2003140308261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)