Healthcare Provider Details

I. General information

NPI: 1467587683
Provider Name (Legal Business Name): GEORGE KRESOVICH OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1574 BELLA VISTA DR
ENCINITAS CA
92024-1265
US

IV. Provider business mailing address

1574BELLA VISTA DRIVE
ENCINITAS CA
92024
US

V. Phone/Fax

Practice location:
  • Phone: 760-943-0307
  • Fax:
Mailing address:
  • Phone: 760-943-0307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOE004686
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: