Provider Demographics
NPI:1518928985
Name:GIOVAGNOLI, DANIEL KEITH (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:KEITH
Last Name:GIOVAGNOLI
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:PO BOX 4405
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:CO
Mailing Address - Zip Code:81631-4405
Mailing Address - Country:US
Mailing Address - Phone:970-328-0365
Mailing Address - Fax:
Practice Address - Street 1:201 GOLDEN EAGLE UNIT A-2
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:CO
Practice Address - Zip Code:81631-4405
Practice Address - Country:US
Practice Address - Phone:970-328-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2009-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1437152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COU09930Medicare UPIN