Provider Demographics
NPI:1205891025
Name:BOZARTH, DANIEL WAYNE (MD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:WAYNE
Last Name:BOZARTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 678207
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8207
Mailing Address - Country:US
Mailing Address - Phone:800-841-4236
Mailing Address - Fax:706-653-1162
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6522
Practice Address - Fax:888-972-8644
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC523092085R0202X, 2085R0204X
IN01059085A2085R0202X
TXM10322085R0202X
MI43010914592085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCD6671324Medicaid
IN200828940Medicaid
IN000000392894OtherANTHEM 351158723
IN000000392992OtherANTHEM 352047427
TX174367601Medicaid
IN000000492336OtherANTHEM 203778927
INQ0433402OtherCMOSHO351158723-352047427
IN073937OtherSIHO 351158723
IN026010MMMMedicare ID - Type Unspecified351158723
IN000000392992OtherANTHEM 352047427
IN000000492336OtherANTHEM 203778927
IN073939OtherSIHO 352047427