Provider Demographics
NPI:1285621896
Name:TALLEY, DANIEL A (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:A
Last Name:TALLEY
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:PO BOX 683
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:KY
Mailing Address - Zip Code:42445-0683
Mailing Address - Country:US
Mailing Address - Phone:270-365-6627
Mailing Address - Fax:
Practice Address - Street 1:101 E SHEPARDSON ST
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:KY
Practice Address - Zip Code:42445-1633
Practice Address - Country:US
Practice Address - Phone:270-365-6627
Practice Address - Fax:270-365-7700
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-29
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY933-DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY77009330Medicaid
KYP00749550Medicare PIN
KY580001093Medicare PIN
KY77009330Medicaid
KY0391780001Medicare NSC
KY00621003Medicare PIN
KY0383001Medicare PIN