Provider Demographics
NPI:1982697686
Name:KRUSE, DAVID M (OD PA)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:KRUSE
Suffix:
Gender:M
Credentials:OD PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:709 2ND ST
Mailing Address - Street 2:PO BOX 89
Mailing Address - City:JACKSON
Mailing Address - State:MN
Mailing Address - Zip Code:56143-1647
Mailing Address - Country:US
Mailing Address - Phone:507-847-5951
Mailing Address - Fax:507-847-5957
Practice Address - Street 1:709 2ND ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MN
Practice Address - Zip Code:56143-1647
Practice Address - Country:US
Practice Address - Phone:507-847-5951
Practice Address - Fax:507-847-5957
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-26
Last Update Date:2011-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNMN1915152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN410040208OtherMEDICARE RAILROAD
MN419000451OtherMEDICARE PTAN
MN826523200Medicaid
MN419000451OtherMEDICARE PTAN