=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982697686
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID M KRUSE OD PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2005
-----------------------------------------------------
Last Update Date | 08/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 709 2ND ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56143-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-847-5951
-----------------------------------------------------
Fax | 507-847-5957
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 709 2ND ST PO BOX 89
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56143-1647
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-847-5951
-----------------------------------------------------
Fax | 507-847-5957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | MN1915
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------