Provider Demographics
NPI:1891707550
Name:DANIEL, JAMIE DYLAN
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:DYLAN
Last Name:DANIEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2301 SE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34471-5114
Mailing Address - Country:US
Mailing Address - Phone:352-867-8551
Mailing Address - Fax:352-867-7669
Practice Address - Street 1:2301 SE 3RD AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-5114
Practice Address - Country:US
Practice Address - Phone:352-867-8551
Practice Address - Fax:352-867-7669
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME93416174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL275026100Medicaid
FL28617Medicare ID - Type Unspecified
FL275026100Medicaid