Provider Demographics
NPI:1972609303
Name:KRISTIN F ENGSTROM, O.D. PC
Entity type:Organization
Organization Name:KRISTIN F ENGSTROM, O.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:ENGSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-281-2746
Mailing Address - Street 1:4731 13TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7205
Mailing Address - Country:US
Mailing Address - Phone:701-281-2746
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND582152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND60598Medicaid
ND60598Medicaid
NDU79345Medicare UPIN