Healthcare Provider Details

I. General information

NPI: 1023002458
Provider Name (Legal Business Name): DANIEL DEJARNATT OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 05/29/2014
Certification Date:
Deactivation Date: 03/27/2006
Reactivation Date: 04/04/2006

III. Provider practice location address

2300 THORNTON TAYLOR PKWY STE C
FAYETTEVILLE TN
37334-3655
US

IV. Provider business mailing address

2300 THORNTON TAYLOR PKWY STE C
FAYETTEVILLE TN
37334-3655
US

V. Phone/Fax

Practice location:
  • Phone: 931-433-3084
  • Fax: 931-433-4188
Mailing address:
  • Phone: 931-433-3084
  • Fax: 931-433-4188

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1046
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: