Healthcare Provider Details

I. General information

NPI: 1912969056
Provider Name (Legal Business Name): MARISA ANN ATRIA KRUGER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2006
Last Update Date: 11/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 S UNION BLVD #460
LAKEWOOD CO
80228-2215
US

IV. Provider business mailing address

165 S UNION BLVD 460
LAKEWOOD CO
80228-2215
US

V. Phone/Fax

Practice location:
  • Phone: 303-865-4290
  • Fax: 303-865-4294
Mailing address:
  • Phone: 303-865-4290
  • Fax: 303-865-4294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152WV0400X
TaxonomyVision Therapy Optometrist
License Number99142899
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: