Healthcare Provider Details

I. General information

NPI: 1831543362
Provider Name (Legal Business Name): OKALOOSA OPHTHALMOLOGY PEDIATRIC & ADULT EYE CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 10/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1299 INDUSTRIAL DR SUITE 200
CRESTVIEW FL
32539-8946
US

IV. Provider business mailing address

1299 INDUSTRIAL DR SUITE 200
CRESTVIEW FL
32539-8946
US

V. Phone/Fax

Practice location:
  • Phone: 850-683-3937
  • Fax: 850-683-0227
Mailing address:
  • Phone: 850-683-3937
  • Fax: 850-683-0227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number
License Number State

VIII. Authorized Official

Name: TIFFANY KRUGER
Title or Position: OWNER
Credential: MD
Phone: 850-826-2903