Provider Demographics
NPI:1154314268
Name:TILLER, DANIEL L (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:L
Last Name:TILLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 12TH AVE S
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83651-4658
Mailing Address - Country:US
Mailing Address - Phone:208-466-9251
Mailing Address - Fax:208-463-1714
Practice Address - Street 1:901 12TH AVE S
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83651-4658
Practice Address - Country:US
Practice Address - Phone:208-466-9251
Practice Address - Fax:208-463-1714
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-696152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV5475OtherBLUE CROSS OF ID
ID000010015295OtherREGENCEY OF IDAHO
ID807007400Medicaid
IDT44345Medicare UPIN
ID1591381Medicare ID - Type Unspecified