Basic Information
| Provider Information | |||||||||
| NPI: | 1427058411 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DAVID | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1019 W OAKLAND AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376042357 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239155000 | ||||||||
| FaxNumber: | 4239155045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1019 W OAKLAND AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239155000 | ||||||||
| FaxNumber: | 4239155045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2005 | ||||||||
| LastUpdateDate: | 06/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101030795 | VA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 016413 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1507565 | 05 | TN | MEDICAID | P00920873 | 01 | TN | RR MEDICARE | OTHER | Q003268 | 05 | TN | MEDICAID | 1427058411 | 05 | VA | MEDICAID |