Basic Information
| Provider Information | |||||||||
| NPI: | 1356348254 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDANIEL | ||||||||
| FirstName: | DEBRA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474035001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123331616 | ||||||||
| FaxNumber: | 8123357604 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 S LANDMARK AVE | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474035001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123331616 | ||||||||
| FaxNumber: | 8123357604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2005 | ||||||||
| LastUpdateDate: | 12/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 01031082A | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 100195300A | 05 | IN | MEDICAID |