Basic Information
| Provider Information | |||||||||
| NPI: | 1518924844 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIEL | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8310 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 24014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Practice Location | |||||||||
| Address1: | 1710 HARPER ROAD | ||||||||
| Address2: | |||||||||
| City: | BECKLEY | ||||||||
| State: | WV | ||||||||
| PostalCode: | 25801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403453556 | ||||||||
| FaxNumber: | 5403422193 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 03/12/2008 | ||||||||
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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 | 2085R0202X | 13630 | WV | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 0117964000 | 05 | WV | MEDICAID |