Provider Demographics
NPI:1932353323
Name:DR DANIEL PUETZ OPTOMETRIST PC
Entity Type:Organization
Organization Name:DR DANIEL PUETZ OPTOMETRIST PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:G
Authorized Official - Last Name:PUETZ
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:636-343-8666
Mailing Address - Street 1:920 BROOKWOOD CTR
Mailing Address - Street 2:
Mailing Address - City:FENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63026-3474
Mailing Address - Country:US
Mailing Address - Phone:636-343-8666
Mailing Address - Fax:
Practice Address - Street 1:920 BROOKWOOD CTR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MO
Practice Address - Zip Code:63026-3474
Practice Address - Country:US
Practice Address - Phone:636-343-8666
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-11
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA1389Medicare PIN