Provider Demographics
NPI:1427256494
Name:DR. MARK O'DANIEL & ASSOCIATES, P.A.
Entity type:Organization
Organization Name:DR. MARK O'DANIEL & ASSOCIATES, P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:BARNARD
Authorized Official - Last Name:O'DANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:252-937-8222
Mailing Address - Street 1:3031 ZEBULON RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27804-2422
Mailing Address - Country:US
Mailing Address - Phone:252-937-8222
Mailing Address - Fax:252-937-6622
Practice Address - Street 1:3031 ZEBULON RD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2422
Practice Address - Country:US
Practice Address - Phone:252-937-8222
Practice Address - Fax:252-937-6622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-11
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC97001162084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903546Medicaid
NC6006055Medicaid
NC135V6OtherBLUE CROSS BLUE SHIELD
NC5903560Medicaid
NC89135V6Medicaid
NC018TJOtherBLUE CROSS BLUE SHIELD
NC89135V6Medicaid
NC2011617EMedicare PIN
NC6006055Medicaid