Provider Demographics
NPI:1164037495
Name:FREITAG, BRETT DAVID (OD)
Entity Type:Individual
Prefix:
First Name:BRETT
Middle Name:DAVID
Last Name:FREITAG
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 1:3 SHADOW CREEK CT
Mailing Address - Street 2:
Mailing Address - City:LAKE IN THE HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:60156-5930
Mailing Address - Country:US
Mailing Address - Phone:815-236-7278
Mailing Address - Fax:
Practice Address - Street 1:5006 NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7339
Practice Address - Country:US
Practice Address - Phone:779-205-0315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-14
Last Update Date:2020-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011472152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist