Provider Demographics
NPI:1477564771
Name:HAIVALA, KATHRYN OPBROEK (OD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:OPBROEK
Last Name:HAIVALA
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 1:1710 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SPEARFISH
Mailing Address - State:SD
Mailing Address - Zip Code:57783
Mailing Address - Country:US
Mailing Address - Phone:605-642-8480
Mailing Address - Fax:605-642-8185
Practice Address - Street 1:1710 NORTH AVE
Practice Address - Street 2:
Practice Address - City:SPEARFISH
Practice Address - State:SD
Practice Address - Zip Code:57783
Practice Address - Country:US
Practice Address - Phone:605-642-8480
Practice Address - Fax:605-642-8185
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY119816500OtherEQUALITY CARE
SD9202840Medicaid
SD4995272OtherBLUE CROSS
5406Medicare UPIN
SD9202840Medicaid