Healthcare Provider Details

I. General information

NPI: 1134209679
Provider Name (Legal Business Name): KRISTIE K. YEAGER O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 W. MORELAND BOULEVARD
WAUKESHA WI
53188
US

IV. Provider business mailing address

11103 WEST AVENUE STE 6
SAN ANTONIO TX
78213
US

V. Phone/Fax

Practice location:
  • Phone: 414-542-9610
  • Fax: 414-542-1783
Mailing address:
  • Phone: 210-524-6803
  • Fax: 210-524-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2530-035
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: