Provider Demographics
NPI:1770569998
Name:FREITAG, MARY LOU (OD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:LOU
Last Name:FREITAG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:LOU
Other - Last Name:FREITAG
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:2001 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:GREELEY
Mailing Address - State:CO
Mailing Address - Zip Code:80634-3250
Mailing Address - Country:US
Mailing Address - Phone:970-330-7070
Mailing Address - Fax:970-330-8382
Practice Address - Street 1:2001 46TH AVE
Practice Address - Street 2:
Practice Address - City:GREELEY
Practice Address - State:CO
Practice Address - Zip Code:80634-3250
Practice Address - Country:US
Practice Address - Phone:970-330-7070
Practice Address - Fax:970-330-8382
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2010-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO799152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0331790002Medicare NSC
COT60885Medicare UPIN
COCF0123Medicare PIN