Provider Demographics
NPI:1720049364
Name:DANIELS, JEWELL L JR (MD)
Entity Type:Individual
Prefix:
First Name:JEWELL
Middle Name:L
Last Name:DANIELS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 W OKMULGEE ST
Mailing Address - Street 2:
Mailing Address - City:MUSKOGEE
Mailing Address - State:OK
Mailing Address - Zip Code:74401-4646
Mailing Address - Country:US
Mailing Address - Phone:918-683-5025
Mailing Address - Fax:918-913-9703
Practice Address - Street 1:4200 W OKMULGEE ST
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-4646
Practice Address - Country:US
Practice Address - Phone:918-683-5025
Practice Address - Fax:918-913-9703
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK23095208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200039920AMedicaid
OK244318401Medicare PIN
OK200039920AMedicaid