Provider Demographics
NPI:1912110578
Name:CONSTANCE, DANIEL GLENN (MD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GLENN
Last Name:CONSTANCE
Suffix:
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 1:5606 SW LEE BLVD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-0000
Mailing Address - Country:US
Mailing Address - Phone:580-536-1111
Mailing Address - Fax:580-536-2211
Practice Address - Street 1:5606 SW LEE BOULEVARD
Practice Address - Street 2:SUITE 203
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73505
Practice Address - Country:US
Practice Address - Phone:580-536-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301082389207R00000X, 207RG0300X, 207RS0010X
OK26711207R00000X, 207RG0300X, 207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine