Provider Demographics
NPI:1366497877
Name:FRITH, THERESA L (OD)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:L
Last Name:FRITH
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 1:1626 TUTTLE ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BARABOO
Mailing Address - State:WI
Mailing Address - Zip Code:53913-1501
Mailing Address - Country:US
Mailing Address - Phone:608-356-2020
Mailing Address - Fax:608-355-7055
Practice Address - Street 1:1626 TUTTLE ST
Practice Address - Street 2:
Practice Address - City:BARABOO
Practice Address - State:WI
Practice Address - Zip Code:53913-1501
Practice Address - Country:US
Practice Address - Phone:608-356-2020
Practice Address - Fax:608-355-7055
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2809-035152W00000X
IN18002877A152W00000X
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1366497877Medicaid
WIK400341211Medicare PIN