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General NPI Number Information
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NPI Number | 1255323952
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Entity Type | Individual
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Provider Name | KIRK JUSTIN KOOGLER OD
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Gender | Male
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Dates
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Enumeration Date | 08/18/2005
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Last Update Date | 05/16/2022
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Provider Practice Location Address
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Address Line | 510 E SOUTHLAKE BLVD STE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6579
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Country | US
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Telephone | 817-481-1665
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Fax | 817-329-7613
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Provider Business Mailing Address
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Address Line | 510 E SOUTHLAKE BLVD STE 100
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City | SOUTHLAKE
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State | TX
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Zip | 76092-6579
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Country | US
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Telephone | 817-481-1665
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Fax | 817-329-7613
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 5135TG
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License Number State | TX
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