Provider Demographics
NPI:1114082443
Name:BEERNTSEN, KATHERINE (OD)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BEERNTSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1680 HAWKINSON RD
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-2306
Mailing Address - Country:US
Mailing Address - Phone:608-873-9680
Mailing Address - Fax:
Practice Address - Street 1:2500 MILTON AVE
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0452
Practice Address - Country:US
Practice Address - Phone:608-757-2633
Practice Address - Fax:608-757-2625
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2009-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2338152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38599500Medicaid
WIU62532Medicare UPIN
WI000147625Medicare ID - Type UnspecifiedOD PIN