Provider Demographics
NPI:1508814435
Name:HOST, DAN R (OD)
Entity Type:Individual
Prefix:DR
First Name:DAN
Middle Name:R
Last Name:HOST
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 1:518 N JEFFERSON ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:46750-2747
Mailing Address - Country:US
Mailing Address - Phone:260-356-4322
Mailing Address - Fax:260-356-4326
Practice Address - Street 1:518 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:IN
Practice Address - Zip Code:46750-2747
Practice Address - Country:US
Practice Address - Phone:260-356-4322
Practice Address - Fax:260-356-4326
Is Sole Proprietor?:No
Enumeration Date:2006-05-04
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18001796152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100138000Medicaid
410047475Medicare PIN
IN5609390001Medicare NSC
INT34712Medicare UPIN
IN220110AMedicare PIN