MEDICARE: DR. DANIEL J. NIEDERKOHR O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3083	OH

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1376592618
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DANIEL J. NIEDERKOHR O.D.

Provider Business Mailing Address
First Line	:	105 MOREY DR
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-1647
Country	:	US
Telephone Number	:	937-642-1916
Fax Number	:	937-642-3620

Provider Business Practice Location Address
First Line	:	105 MOREY DR
Second Line	:
City	:	MARYSVILLE
State	:	OH
Zip	:	43040-1647
Country	:	US
Telephone Number	:	937-642-1916
Fax Number	:	937-642-3620

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	03/24/2008

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