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NPI Code Detail

MEDICARE: DR. KRISTINA M BORESPUPP OD

MEDICARE: DR. KRISTINA M BORESPUPP OD
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
1152W00000XOptometrist2479MN

General Provider Information

NPI Number : 1831159680
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. KRISTINA M BORESPUPP OD
Provider Business Mailing Address
First Line : 3715 MARSH PT W
Second Line :
City : INDEPENDENCE
State : MN
Zip : 55359-9820
Country : US
Telephone Number : 763-479-3794
Fax Number :
Provider Business Practice Location Address
First Line : 4455 HIGHWAY 169 N
Second Line :
City : PLYMOUTH
State : MN
Zip : 55442-2897
Country : US
Telephone Number : 763-551-0529
Fax Number : 763-559-6010
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/24/2006
Last Update Date : 07/08/2007

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