Provider Demographics
NPI:1245243245
Name:THIEME, DAN C (OD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:C
Last Name:THIEME
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 1:1648 NW 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2224
Mailing Address - Country:US
Mailing Address - Phone:208-888-2200
Mailing Address - Fax:208-888-7623
Practice Address - Street 1:1648 NW 2ND ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2224
Practice Address - Country:US
Practice Address - Phone:208-888-2200
Practice Address - Fax:208-888-7623
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDV902-2OtherBLUE CROSS
ID000010015459OtherBLUE SHIELD #
ID001519300Medicaid
ID1594259Medicare PIN