Provider Demographics
NPI:1659636017
Name:BALCUEVA, DANIEL G (OD)
Entity Type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:G
Last Name:BALCUEVA
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 1:655 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:MADISON HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48071-1850
Mailing Address - Country:US
Mailing Address - Phone:248-588-9300
Mailing Address - Fax:248-588-9917
Practice Address - Street 1:735 JOHN R RD
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-5856
Practice Address - Country:US
Practice Address - Phone:248-544-3290
Practice Address - Fax:248-528-4040
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18003721152W00000X
MI4901004830152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201202570Medicaid
MI1659636017Medicaid
IN411610001Medicare PIN
MIM30440119Medicare PIN