Provider Demographics
NPI:1013283449
Name:MCDANIEL, RENNY THEODORE (MD, MPH)
Entity type:Individual
Prefix:DR
First Name:RENNY
Middle Name:THEODORE
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPANISH FORK
Mailing Address - State:UT
Mailing Address - Zip Code:84660-2060
Mailing Address - Country:US
Mailing Address - Phone:801-798-7301
Mailing Address - Fax:801-798-8513
Practice Address - Street 1:15 S 1000 E STE 100
Practice Address - Street 2:
Practice Address - City:PAYSON
Practice Address - State:UT
Practice Address - Zip Code:84651-5592
Practice Address - Country:US
Practice Address - Phone:801-465-9480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ4631207Q00000X
UT10738150-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX348324001Medicaid
TX431862YK7YMedicare PIN