Provider Demographics
NPI:1700899911
Name:DAN C. THIEME O.D., P.C
Entity Type:Organization
Organization Name:DAN C. THIEME O.D., P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:THIEME
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:208-888-2200
Mailing Address - Street 1:1648 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-2224
Mailing Address - Country:US
Mailing Address - Phone:208-888-2200
Mailing Address - Fax:208-888-7623
Practice Address - Street 1:1648 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-2224
Practice Address - Country:US
Practice Address - Phone:208-888-2200
Practice Address - Fax:208-888-7623
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID0-901152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT1560526754529OtherVSP MEMBER NUMBER
ID000010015459OtherBLUE SHIELD
ID001519300Medicaid
IDV902-2OtherBLUE CROSS
IDU53088Medicare UPIN
ID1376999Medicare PIN
ID000010015459OtherBLUE SHIELD
IDS025Medicare ID - Type Unspecified
ID1594259Medicare PIN