Provider Demographics
NPI:1871585018
Name:O'DANIEL, THOMAS G JR (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:G
Last Name:O'DANIEL
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 S 1ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1350
Mailing Address - Country:US
Mailing Address - Phone:502-584-1109
Mailing Address - Fax:502-589-6882
Practice Address - Street 1:222 S 1ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1350
Practice Address - Country:US
Practice Address - Phone:502-584-1109
Practice Address - Fax:502-589-6882
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY240702086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100033340AMedicaid
KY002OtherCIGNA
KY1058697OtherPASSPORT PIN
KY667357OtherHEALTHLINK
KYKY0057799OtherTRICARE
KYKY1118OtherHEALTHNET PIN
KY000000219660OtherANTHEM PIN
KY64240708Medicaid
KY000000219660OtherANTHEM PIN
KY1058697OtherPASSPORT PIN
KY667357OtherHEALTHLINK