Provider Demographics
NPI:1366576399
Name:DANIEL, THADDEUS
Entity type:Individual
Prefix:DR
First Name:THADDEUS
Middle Name:
Last Name:DANIEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:THAD
Other - Middle Name:
Other - Last Name:DANIEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:1244 E GREEN BAY ST
Mailing Address - Street 2:
Mailing Address - City:SHAWANO
Mailing Address - State:WI
Mailing Address - Zip Code:54166-2208
Mailing Address - Country:US
Mailing Address - Phone:715-526-2376
Mailing Address - Fax:715-526-9651
Practice Address - Street 1:1244 E GREEN BAY ST
Practice Address - Street 2:OPTICAL DEPT
Practice Address - City:SHAWANO
Practice Address - State:WI
Practice Address - Zip Code:54166-2208
Practice Address - Country:US
Practice Address - Phone:715-526-2376
Practice Address - Fax:715-526-9651
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2396152W00000X
WI2359152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO810015Medicare PIN
COU30493Medicare UPIN