Provider Demographics
NPI:1780790154
Name:DAN C THIEME OD PC
Entity type:Organization
Organization Name:DAN C THIEME OD PC
Other - Org Name:<UNAVAIL>
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:208-642-4434
Mailing Address - Street 1:827 CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:PAYETTE
Mailing Address - State:ID
Mailing Address - Zip Code:83661-2535
Mailing Address - Country:US
Mailing Address - Phone:208-642-4434
Mailing Address - Fax:208-642-1433
Practice Address - Street 1:827 CENTER AVE
Practice Address - Street 2:
Practice Address - City:PAYETTE
Practice Address - State:ID
Practice Address - Zip Code:83661-2535
Practice Address - Country:US
Practice Address - Phone:208-642-4434
Practice Address - Fax:208-642-1433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2008-12-11
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
ID000010015223OtherBLUE SHIELD
ID001519301Medicaid
IDV6002OtherBLUE CROSS
ID4992280001Medicare NSC
1376990Medicare PIN