Provider Demographics
NPI:1699767442
Name:LANTZ, DANIEL T (OD)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:T
Last Name:LANTZ
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 257
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-0257
Mailing Address - Country:US
Mailing Address - Phone:712-542-6521
Mailing Address - Fax:712-542-4209
Practice Address - Street 1:203 S 16TH ST
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2107
Practice Address - Country:US
Practice Address - Phone:712-542-6521
Practice Address - Fax:712-542-4209
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1803152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0218172Medicaid
IA0560810001Medicare NSC
IAT01235Medicare UPIN
IA0218172Medicaid