Provider Demographics
NPI:1417069287
Name:MICKEY, DANIEL KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:KEITH
Last Name:MICKEY
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 1:1371 29TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:NE
Mailing Address - Zip Code:68601-4926
Mailing Address - Country:US
Mailing Address - Phone:402-564-0545
Mailing Address - Fax:402-564-0078
Practice Address - Street 1:1371 29TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:NE
Practice Address - Zip Code:68601
Practice Address - Country:US
Practice Address - Phone:402-564-0545
Practice Address - Fax:402-564-0078
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1069152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH1483OtherRAILROAD MEDICARE GROUP #
NE47055862700Medicaid
06952OtherBCBS
U57090Medicare UPIN
NE47055862700Medicaid
NE0313770001Medicare NSC
06952OtherBCBS
NE266987Medicare PIN