Provider Demographics
NPI:1962515791
Name:KOONS, KREGG C (OD OPTOMETRY)
Entity type:Individual
Prefix:DR
First Name:KREGG
Middle Name:C
Last Name:KOONS
Suffix:
Gender:M
Credentials:OD OPTOMETRY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 S BUCKINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:YORKTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47396-9253
Mailing Address - Country:US
Mailing Address - Phone:765-722-0140
Mailing Address - Fax:
Practice Address - Street 1:3300 W FOX RIDGE LN
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47304-5201
Practice Address - Country:US
Practice Address - Phone:765-289-4727
Practice Address - Fax:765-751-2207
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2015-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2701152W00000X
IN18002701B152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100376600Medicaid
IN100376600Medicaid
IN507020DMedicare ID - Type Unspecified