Healthcare Provider Details

I. General information

NPI: 1073815932
Provider Name (Legal Business Name): ROBERT C. MCDANIEL, M.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 W LOOP 281
LONGVIEW TX
75604-2506
US

IV. Provider business mailing address

2101 W LOOP 281
LONGVIEW TX
75604-2506
US

V. Phone/Fax

Practice location:
  • Phone: 903-248-0494
  • Fax: 903-248-9137
Mailing address:
  • Phone: 903-248-0494
  • Fax: 903-248-9137

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberD-5133
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License NumberD-5133
License Number StateTX

VIII. Authorized Official

Name: MS. CAROLYN S. MCDANIEL
Title or Position: ADMINISTRATIVE SECRETARY
Credential:
Phone: 903-248-0494