Provider Demographics
NPI:1134271323
Name:MCDANIEL, RONN E (OD)
Entity type:Individual
Prefix:
First Name:RONN
Middle Name:E
Last Name:MCDANIEL
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 1:100 LAKE TRAVERSE DR
Mailing Address - Street 2:
Mailing Address - City:SISSETON
Mailing Address - State:SD
Mailing Address - Zip Code:57262-7046
Mailing Address - Country:US
Mailing Address - Phone:605-742-3620
Mailing Address - Fax:605-742-3881
Practice Address - Street 1:128 2ND ST NW
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1409
Practice Address - Country:US
Practice Address - Phone:320-839-3413
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2619152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN5C857MCOtherBLUE CROSS BLUE SHIELD
MN848152100Medicaid
MNU66339Medicare UPIN
MN1173070001Medicare NSC
MN410000900Medicare PIN
MN5C857MCOtherBLUE CROSS BLUE SHIELD