Provider Demographics
NPI:1063786317
Name:DAVID R MCDANIEL OD PA
Entity type:Organization
Organization Name:DAVID R MCDANIEL OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:704-739-1394
Mailing Address - Street 1:510 W KING ST
Mailing Address - Street 2:PO BOX 1127
Mailing Address - City:KINGS MTN
Mailing Address - State:NC
Mailing Address - Zip Code:28086-3310
Mailing Address - Country:US
Mailing Address - Phone:704-739-1394
Mailing Address - Fax:
Practice Address - Street 1:510 W KING ST
Practice Address - Street 2:
Practice Address - City:KINGS MTN
Practice Address - State:NC
Practice Address - Zip Code:28086-3310
Practice Address - Country:US
Practice Address - Phone:704-739-1394
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-05
Last Update Date:2012-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCNC0991152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC246348OtherMEDICARE PTAN
NC8909569Medicaid
NCT64890Medicare UPIN