Provider Demographics
NPI:1134214216
Name:PUETZ, DANIEL GERARD (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:GERARD
Last Name:PUETZ
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 1:920 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:636-326-1400
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:636-326-1400
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO2530152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO311907109Medicaid
MO000007421Medicare ID - Type Unspecified
MO311907109Medicaid