Basic Information
| Provider Information | |||||||||
| NPI: | 1740385541 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVERY | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | BEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3400C OLD MILTON PKWY STE 270 | ||||||||
| Address2: | |||||||||
| City: | ALPHARETTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 300054438 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7704421911 | ||||||||
| FaxNumber: | 4782466155 | ||||||||
| Practice Location | |||||||||
| Address1: | 230 INDUSTRIAL BLVD STE D | ||||||||
| Address2: | |||||||||
| City: | DUBLIN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 310212904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4782721366 | ||||||||
| FaxNumber: | 4782752322 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 12/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 058439 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 526388566C | 05 | GA | MEDICAID |