Provider Demographics
NPI:1740779388
Name:KVIDT, BLAKE (OD)
Entity Type:Individual
Prefix:DR
First Name:BLAKE
Middle Name:
Last Name:KVIDT
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 1:135 N SIBLEY AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55355-2138
Mailing Address - Country:US
Mailing Address - Phone:320-593-3100
Mailing Address - Fax:
Practice Address - Street 1:135 N SIBLEY AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55355-2138
Practice Address - Country:US
Practice Address - Phone:320-593-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-09
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND755152W00000X
MN3599152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist