Provider Demographics
NPI:1366430068
Name:WITTROCK, KRISTINA NICOLE (OD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:NICOLE
Last Name:WITTROCK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6630 MILLS CIVIC PKWY UNIT 6120
Mailing Address - Street 2:
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-8371
Mailing Address - Country:US
Mailing Address - Phone:515-225-6447
Mailing Address - Fax:515-226-2347
Practice Address - Street 1:6630 MILLS CIVIC PKWY UNIT 6120
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-8371
Practice Address - Country:US
Practice Address - Phone:515-225-6447
Practice Address - Fax:515-226-2347
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2024-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA002409152W00000X
MI4901003786152WC0802X, 152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Not Answered152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Not Answered152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIKW003876OtherBCBSM PIN
MIU58232Medicare UPIN