Provider Demographics
NPI:1730453051
Name:WENDELL D. DANIELS M.D., P.A.
Entity type:Organization
Organization Name:WENDELL D. DANIELS M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:DANIELS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:903-757-7377
Mailing Address - Street 1:P.O. BOX 3406
Mailing Address - Street 2:515 N. THIRD ST.
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:515 N. 3RD ST.
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75606
Practice Address - Country:US
Practice Address - Phone:903-757-7377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WENDELL D. DANIELS M.D., P.A.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-03-05
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE6058207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0990236-01Medicaid
00JJ33Medicare PIN
TX0990236-01Medicaid