Provider Demographics
NPI:1376592618
Name:NIEDERKOHR, DANIEL J (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:J
Last Name:NIEDERKOHR
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 1:105 MOREY DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1647
Mailing Address - Country:US
Mailing Address - Phone:937-642-1916
Mailing Address - Fax:937-642-3620
Practice Address - Street 1:105 MOREY DR
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1647
Practice Address - Country:US
Practice Address - Phone:937-642-1916
Practice Address - Fax:937-642-3620
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3083152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0306387Medicaid
0441110001Medicare NSC
OH0306387Medicaid
NI0446181Medicare PIN