Healthcare Provider Details

I. General information

NPI: 1184015984
Provider Name (Legal Business Name): MARY MCDANIEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2015
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 ARBUTUS AVE
OCONTO WI
54153-2004
US

IV. Provider business mailing address

PO BOX 23400
GREEN BAY WI
54305-3400
US

V. Phone/Fax

Practice location:
  • Phone: 920-835-1100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number7327
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number81655-20
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: