Provider Demographics
NPI:1356348254
Name:MCDANIEL, DEBRA K (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:K
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 S LANDMARK AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-5001
Mailing Address - Country:US
Mailing Address - Phone:812-333-1616
Mailing Address - Fax:812-335-7604
Practice Address - Street 1:350 S LANDMARK AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-5001
Practice Address - Country:US
Practice Address - Phone:812-333-1616
Practice Address - Fax:812-335-7604
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01031082A208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100195300AMedicaid
INE05780Medicare UPIN
IN548070CMedicare ID - Type Unspecified