Healthcare Provider Details

I. General information

NPI: 1649330671
Provider Name (Legal Business Name): STACEY JILL KRUGER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2006
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NORTH BOULEVARD SUITE 220
GREAT NECK NY
11021
US

IV. Provider business mailing address

600 NORTH BOULEVARD SUITE 220
GREAT NECK NY
11021
US

V. Phone/Fax

Practice location:
  • Phone: 516-470-2020
  • Fax: 516-470-2000
Mailing address:
  • Phone: 516-470-2020
  • Fax: 516-470-2000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME85180
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number211514
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number211514
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: