Provider Demographics
NPI:1588773345
Name:GUY O DANIELSON III, M.D., P.A.
Entity type:Organization
Organization Name:GUY O DANIELSON III, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUY
Authorized Official - Middle Name:O
Authorized Official - Last Name:DANIELSON
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:903-595-8077
Mailing Address - Street 1:PO BOX 6930
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75711-6930
Mailing Address - Country:US
Mailing Address - Phone:903-595-8077
Mailing Address - Fax:903-363-1541
Practice Address - Street 1:1814 ROSELAND BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-4234
Practice Address - Country:US
Practice Address - Phone:903-595-8077
Practice Address - Fax:903-363-1541
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-29
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
0031KVOtherBLUE CROSS BLUE SHIELD
TX168693301Medicaid
TX00891VMedicare PIN