Provider Demographics
NPI:1366576282
Name:MCDANIEL, JEFFREY MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 DON FLOYD DR STE 124
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:TX
Mailing Address - Zip Code:76065-6289
Mailing Address - Country:US
Mailing Address - Phone:972-775-4132
Mailing Address - Fax:972-775-4620
Practice Address - Street 1:979 DON FLOYD DR STE 124
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:TX
Practice Address - Zip Code:76065-6289
Practice Address - Country:US
Practice Address - Phone:972-775-4132
Practice Address - Fax:972-775-4620
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN5855207QS0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X0098OtherBLUE CROSS AND BLUE SHIELD OF TEXAS
TX217145602Medicaid
TXTXB111462Medicare PIN