Healthcare Provider Details

I. General information

NPI: 1063524775
Provider Name (Legal Business Name): DAVID PAUL KRUGER OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 BROADMEADOW RD
RANTOUL IL
61866-2119
US

IV. Provider business mailing address

325 E CONGRESS AVE
RANTOUL IL
61866-2402
US

V. Phone/Fax

Practice location:
  • Phone: 217-892-5095
  • Fax: 217-892-5097
Mailing address:
  • Phone: 217-892-1845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number046007718
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: