Provider Demographics
NPI:1801905674
Name:DANIELSON, GUY O III (MD)
Entity type:Individual
Prefix:
First Name:GUY
Middle Name:O
Last Name:DANIELSON
Suffix:III
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:PO BOX 6930
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6930
Mailing Address - Country:US
Mailing Address - Phone:903-595-8077
Mailing Address - Fax:903-363-1541
Practice Address - Street 1:1814 ROSELAND BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4244
Practice Address - Country:US
Practice Address - Phone:903-595-8077
Practice Address - Fax:903-363-1541
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE7042207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX137457111Medicaid
8K6370OtherBLUE CROSS BLUE SHIELD
8K6370OtherBLUE CROSS BLUE SHIELD
B22111Medicare UPIN