MEDICARE: DR. KRISTEN KINGSBURY DESAUTEL O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3201	MN

General Provider Information

NPI Number	:	1578874814
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KRISTEN KINGSBURY DESAUTEL O.D.

Provider Business Mailing Address
First Line	:	5980 NEAL AVE N STE 500
Second Line	:
City	:	OAK PARK HEIGHTS
State	:	MN
Zip	:	55082-2195
Country	:	US
Telephone Number	:	651-998-2020
Fax Number	:	651-342-1407

Provider Business Practice Location Address
First Line	:	5980 NEAL AVE N STE 500
Second Line	:
City	:	OAK PARK HEIGHTS
State	:	MN
Zip	:	55082-2195
Country	:	US
Telephone Number	:	651-998-2020
Fax Number	:	651-342-1407

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2010
Last Update Date	:	12/12/2023

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