Provider Demographics
NPI:1861475709
Name:BRATVOLD, CRAIG A (OD)
Entity Type:Individual
Prefix:
First Name:CRAIG
Middle Name:A
Last Name:BRATVOLD
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 1:24226 RIDGEVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-7151
Mailing Address - Country:US
Mailing Address - Phone:218-849-4295
Mailing Address - Fax:218-847-8453
Practice Address - Street 1:1583 HIGHWAY 10 W
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2232
Practice Address - Country:US
Practice Address - Phone:218-847-7245
Practice Address - Fax:218-847-8453
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-23
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2434152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410003242OtherMEDICARE PTAN