Healthcare Provider Details

I. General information

NPI: 1730402975
Provider Name (Legal Business Name): DEDRICK MICHELLE DANIELS DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2010
Last Update Date: 07/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1760 EDGEWOOD AVE W
JACKSONVILLE FL
32208-7209
US

IV. Provider business mailing address

1760 EDGEWOOD AVE W
JACKSONVILLE FL
32208-7209
US

V. Phone/Fax

Practice location:
  • Phone: 917-686-1831
  • Fax: 205-879-8259
Mailing address:
  • Phone: 917-686-1831
  • Fax: 205-879-8259

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery
License NumberPOD001172
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: