Healthcare Provider Details

I. General information

NPI: 1598830036
Provider Name (Legal Business Name): THEODORE L. FRITSCHE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

IV. Provider business mailing address

300 S BRUCE ST
MARSHALL MN
56258-1934
US

V. Phone/Fax

Practice location:
  • Phone: 507-537-1427
  • Fax: 507-537-1742
Mailing address:
  • Phone: 507-537-1427
  • Fax: 507-537-1742

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number18615
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: