Healthcare Provider Details

I. General information

NPI: 1538220041
Provider Name (Legal Business Name): JONATHAN PERRY KRUGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 06/01/2021
Certification Date: 06/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 LOISDALE CT
SPRINGFIELD VA
22150-1826
US

IV. Provider business mailing address

2101 E JEFFERSON ST KP MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-922-1185
  • Fax: 202-346-3680
Mailing address:
  • Phone: 301-816-2424
  • Fax: 301-816-6308

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101045593
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD53015
License Number StateMD
# 3
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD18670
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: