Provider Demographics
NPI:1063487072
Name:GRIEBENOW, KERRY LEE (OD)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:LEE
Last Name:GRIEBENOW
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 1:105 NORTHRIDGE DR
Mailing Address - Street 2:P.O. BOX 230
Mailing Address - City:NEW LONDON
Mailing Address - State:WI
Mailing Address - Zip Code:54961-2703
Mailing Address - Country:US
Mailing Address - Phone:920-982-3711
Mailing Address - Fax:920-982-3009
Practice Address - Street 1:105 NORTHRIDGE DR
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:WI
Practice Address - Zip Code:54961-2703
Practice Address - Country:US
Practice Address - Phone:920-982-3711
Practice Address - Fax:920-982-3009
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1666152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38510500Medicaid
WI38510500Medicaid
WI47140Medicare ID - Type Unspecified