Provider Demographics
NPI:1457347007
Name:TACKETT, DANIEL MARTIN (MD)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:MARTIN
Last Name:TACKETT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:DAN
Other - Middle Name:M
Other - Last Name:TACKETT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3751 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57701-5363
Mailing Address - Country:US
Mailing Address - Phone:605-341-7248
Mailing Address - Fax:605-431-0268
Practice Address - Street 1:3751 SKYLINE DR
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57701-5363
Practice Address - Country:US
Practice Address - Phone:605-341-7248
Practice Address - Fax:605-431-0268
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD18942085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY102240700Medicaid
920002680OtherRAILROAD MEDICARE
SD7202112Medicaid
WY102240700Medicaid