=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093900177
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN G MCDANIEL, OD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2007
-----------------------------------------------------
Last Update Date | 01/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9777 WIMBLEDON CT
-----------------------------------------------------
City | HIGHLANDS RANCH
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80126-3051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-751-2834
-----------------------------------------------------
Fax | 888-317-1023
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9777 WIMBLEDON CT
-----------------------------------------------------
City | HIGHLANDS RANCH
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80126-3051
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-751-2834
-----------------------------------------------------
Fax | 888-317-1023
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JOHN GORDON MCDANIEL
-----------------------------------------------------
Credential | O.D., M.L.H.R.
-----------------------------------------------------
Telephone | 262-751-2834
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 2702
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------