Provider Demographics
NPI:1114901733
Name:FRIESE, ROBERT (OD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FRIESE
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 1:800 MEDICAL CENTER DR
Mailing Address - Street 2:PO BOX 800
Mailing Address - City:FAIRMONT
Mailing Address - State:MN
Mailing Address - Zip Code:56031-4575
Mailing Address - Country:US
Mailing Address - Phone:507-238-8555
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 800
Practice Address - Street 2:
Practice Address - City:FAIRMONT
Practice Address - State:MN
Practice Address - Zip Code:56031-0800
Practice Address - Country:US
Practice Address - Phone:507-238-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2353207W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN573R3FRMedicaid
MN675185OtherARAZ
MN114854Medicaid
MNMH9041028502OtherPREFERRED ONE
MN22-02567OtherMEDICA
MN441525600Medicaid
IA1160887Medicaid
MN573R3FROtherBLUE CROSS
MN410002301Medicare ID - Type Unspecified
U25845Medicare UPIN
MN573R3FRMedicaid
IA1160887Medicaid
MN410002301Medicare ID - Type UnspecifiedRAILROAD MEDICARE