Provider Demographics
NPI:1669521753
Name:WEBER, DANIEL JOHN (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:WEBER
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 1:1602 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735-1192
Mailing Address - Country:US
Mailing Address - Phone:660-885-8171
Mailing Address - Fax:660-890-8496
Practice Address - Street 1:1602 N 2ND ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MO
Practice Address - Zip Code:64735-1192
Practice Address - Country:US
Practice Address - Phone:660-885-8171
Practice Address - Fax:660-890-8496
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2021-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020034823152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU79939Medicare UPIN
ILL77803Medicare ID - Type Unspecified