Provider Demographics
NPI:1699750075
Name:JACQUES, DANIEL MARK (MD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:MARK
Last Name:JACQUES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DANIEL
Other - Middle Name:
Other - Last Name:JACQUES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1025 VERDAE BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4032
Mailing Address - Country:US
Mailing Address - Phone:864-242-4683
Mailing Address - Fax:864-240-8104
Practice Address - Street 1:317 ST. FRANCIS DRIVE
Practice Address - Street 2:SUITE 360
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29601
Practice Address - Country:US
Practice Address - Phone:864-232-8118
Practice Address - Fax:864-370-2740
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17921208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20051085OtherRR MEDICARE
SC179210Medicaid
SC179210Medicaid
SCG857707104Medicare PIN