Provider Demographics
NPI:1154427565
Name:ENGSTROM, KRISTIN F (OD)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:F
Last Name:ENGSTROM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:F
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:4607 TIMBERLINE DR S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-730-6168
Mailing Address - Fax:701-281-2747
Practice Address - Street 1:4731 13TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-7205
Practice Address - Country:US
Practice Address - Phone:701-281-2746
Practice Address - Fax:701-281-2747
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2017-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND582152W00000X
MN2512152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60597Medicaid
NDN22637Medicare ID - Type Unspecified
ND60597Medicaid