Provider Demographics
NPI:1962693028
Name:PIETIG, TODD RANDALL (OD)
Entity type:Individual
Prefix:DR
First Name:TODD
Middle Name:RANDALL
Last Name:PIETIG
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4105 SW BLUEGRASS DR
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-8280
Mailing Address - Country:US
Mailing Address - Phone:712-830-6806
Mailing Address - Fax:
Practice Address - Street 1:12871 UNIVERSITY AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:CLIVE
Practice Address - State:IA
Practice Address - Zip Code:50325-8255
Practice Address - Country:US
Practice Address - Phone:712-830-6806
Practice Address - Fax:515-221-9196
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002405152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3701163Medicaid
IA3701163Medicaid