Provider Demographics
NPI:1588793731
Name:MCDANIEL, MARIANNE WANDA (OD)
Entity type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:WANDA
Last Name:MCDANIEL
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 ELISABETH DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-7159
Mailing Address - Country:US
Mailing Address - Phone:618-624-3278
Mailing Address - Fax:
Practice Address - Street 1:10900 LINCOLN TRL
Practice Address - Street 2:
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2042
Practice Address - Country:US
Practice Address - Phone:618-398-5005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist