Provider Demographics
NPI:1356550677
Name:MCDANIELS, MICHAEL D (DO)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:D
Last Name:MCDANIELS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:D
Other - Last Name:MCDANIELS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:9505 CHAPARRAL LN
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-4307
Mailing Address - Country:US
Mailing Address - Phone:318-687-6894
Mailing Address - Fax:318-687-6894
Practice Address - Street 1:9505 CHAPARRAL LN
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-4307
Practice Address - Country:US
Practice Address - Phone:318-687-6894
Practice Address - Fax:318-687-6894
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXGO477207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXGO477OtherTEXAS MEDICAL LICENSE NUM
TXGO477OtherTEXAS MEDICAL LICENSE NUM
TX00NT57Medicare ID - Type UnspecifiedMEDICARE NUMBER