MEDICARE: DANIEL P. ETHAKOTI OD

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	2015020209	MO

General Provider Information

NPI Number	:	1740662964
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DANIEL P. ETHAKOTI OD

Provider Business Mailing Address
First Line	:	211 E BROADWAY
Second Line	:
City	:	ALTON
State	:	IL
Zip	:	62002-6220
Country	:	US
Telephone Number	:	618-462-9818
Fax Number	:	800-432-6004

Provider Business Practice Location Address
First Line	:	3732 S KINGSHIGHWAY BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63109-1800
Country	:	US
Telephone Number	:	314-446-1134
Fax Number	:	314-446-1136

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

Provider Enumeration Date	:	06/24/2015
Last Update Date	:	06/24/2015

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