Provider Demographics
NPI:1790942332
Name:KITTELSON, RICHARD NEAL (ABOC)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:NEAL
Last Name:KITTELSON
Suffix:
Gender:M
Credentials:ABOC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:918 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3402
Mailing Address - Country:US
Mailing Address - Phone:218-847-8021
Mailing Address - Fax:218-846-9552
Practice Address - Street 1:918 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-3402
Practice Address - Country:US
Practice Address - Phone:218-847-8021
Practice Address - Fax:218-846-9552
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-21
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN03590156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1C991OPOtherBLUE CROSS BLUE SHIELD OF MINNESOTA
MN498762400Medicaid
MN2100679OtherMEDICA
MN1C991OPOtherBLUE CROSS BLUE SHIELD OF MINNESOTA