Provider Demographics
NPI:1477583466
Name:QUITBERG, JOY M (OD)
Entity Type:Individual
Prefix:
First Name:JOY
Middle Name:M
Last Name:QUITBERG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1245 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3905
Practice Address - Country:US
Practice Address - Phone:218-846-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-04
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2897152W00000X
ND645152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN903130800Medicaid
MN903130800Medicaid
MNH400099269Medicare PIN
U94606Medicare UPIN