Provider Demographics
NPI:1306300926
Name:DANIEL, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DANIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-4004
Mailing Address - Country:US
Mailing Address - Phone:515-573-3431
Mailing Address - Fax:515-573-4116
Practice Address - Street 1:1114 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-4004
Practice Address - Country:US
Practice Address - Phone:515-573-3431
Practice Address - Fax:515-573-4116
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA12617183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA08161937Medicaid