Provider Demographics
NPI:1730402975
Name:DANIELS, DEDRICK MICHELLE (DPM)
Entity type:Individual
Prefix:
First Name:DEDRICK
Middle Name:MICHELLE
Last Name:DANIELS
Suffix:
Gender:F
Credentials:DPM
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 3035
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-3035
Mailing Address - Country:US
Mailing Address - Phone:202-276-9478
Mailing Address - Fax:
Practice Address - Street 1:2251 W ELM ST
Practice Address - Street 2:
Practice Address - City:WRIGHTSVILLE
Practice Address - State:GA
Practice Address - Zip Code:31096-2017
Practice Address - Country:US
Practice Address - Phone:478-864-2600
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2024-03-23
Deactivation Date:2023-12-04
Deactivation Code:
Reactivation Date:2023-12-22
Provider Licenses
StateLicense IDTaxonomies
FLPO3691213ES0103X
GAPOD001172213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP01002642OtherRAILROAD MEDICARE
GA003112635AMedicaid
GA202I487162Medicare PIN
GA003112635AMedicaid