Provider Demographics
NPI:1265404222
Name:DANIELS, DENNIS EDWARDS (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:EDWARDS
Last Name:DANIELS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1906A GREENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2430
Mailing Address - Country:US
Mailing Address - Phone:573-778-5913
Mailing Address - Fax:573-776-7750
Practice Address - Street 1:1906A GREENWOOD DR
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2430
Practice Address - Country:US
Practice Address - Phone:573-778-5913
Practice Address - Fax:573-776-7750
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003009194207RP1001X
WV26336207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO209073204Medicaid
MO501150073Medicare PIN
H34512Medicare UPIN
MOMA1327107Medicare PIN
MO122640012Medicare PIN