=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063524775
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID PAUL KRUGER OD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/31/2006
-----------------------------------------------------
Last Update Date | 10/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 BROADMEADOW RD
-----------------------------------------------------
City | RANTOUL
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61866-2119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-892-5095
-----------------------------------------------------
Fax | 217-892-5097
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 E CONGRESS AVE
-----------------------------------------------------
City | RANTOUL
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61866-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 217-892-1845
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | 046007718
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------