Provider Demographics
NPI:1295849917
Name:KRIETLOW, CHAD M (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAD
Middle Name:M
Last Name:KRIETLOW
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:260 NORTHTOWN DR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55434-1037
Mailing Address - Country:US
Mailing Address - Phone:763-784-9049
Mailing Address - Fax:763-717-6939
Practice Address - Street 1:260 NORTHTOWN DR NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55434-1037
Practice Address - Country:US
Practice Address - Phone:763-784-9049
Practice Address - Fax:763-717-6939
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN2821152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN916244500Medicaid
MNU90305Medicare UPIN
MN916244500Medicaid