Provider Demographics
NPI:1588419220
Name:MCDANIEL, ROD
Entity type:Individual
Prefix:
First Name:ROD
Middle Name:
Last Name:MCDANIEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 NORTHSIDE DR E
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-4760
Mailing Address - Country:US
Mailing Address - Phone:912-764-7914
Mailing Address - Fax:912-764-7352
Practice Address - Street 1:147 NORTHSIDE DR E
Practice Address - Street 2:
Practice Address - City:STATESBORO
Practice Address - State:GA
Practice Address - Zip Code:30458-4760
Practice Address - Country:US
Practice Address - Phone:912-764-7914
Practice Address - Fax:912-764-7352
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002505156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOpticianGroup - Single Specialty