Healthcare Provider Details

I. General information

NPI: 1700860269
Provider Name (Legal Business Name): JEFFREY KRAUSHAAR O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 03/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 ROUTE 25A
SHOREHAM NY
11786-1389
US

IV. Provider business mailing address

45 ROUTE 25A
SHOREHAM NY
11786-1389
US

V. Phone/Fax

Practice location:
  • Phone: 631-821-2244
  • Fax: 631-821-4228
Mailing address:
  • Phone: 631-821-2244
  • Fax: 631-821-4228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberTUV004145-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: