Basic Information
| Provider Information | |||||||||
| NPI: | 1265544217 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DANIELL | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 844658 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752844658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2547248800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 100 HILLCREST MEDICAL BLVD | ||||||||
| Address2: | |||||||||
| City: | WACO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 767128897 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542025800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 02/11/2015 | ||||||||
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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 | 207P00000X | TBXK9761 | TX | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | K9761 | TX | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 930104296 | 01 | TX | RRMCR | OTHER | 8C0340 | 01 | TX | BCBS | OTHER | 043877202 | 05 | TX | MEDICAID |