Provider Demographics
NPI:1811968878
Name:EVERTS, DANIEL R (OD)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:R
Last Name:EVERTS
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 1:308 W FULTON ST
Mailing Address - Street 2:
Mailing Address - City:WAUPACA
Mailing Address - State:WI
Mailing Address - Zip Code:54981
Mailing Address - Country:US
Mailing Address - Phone:715-258-8168
Mailing Address - Fax:715-258-8436
Practice Address - Street 1:308 W FULTON ST
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981
Practice Address - Country:US
Practice Address - Phone:715-258-8168
Practice Address - Fax:715-258-8436
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-30
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2753152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38716100Medicaid
U75930Medicare UPIN
WI0187380001Medicare NSC