Provider Demographics
NPI:1083741839
Name:KRALL, JEFF (OD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:
Last Name:KRALL
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 N SANBORN BLVD
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301-1015
Mailing Address - Country:US
Mailing Address - Phone:605-996-2020
Mailing Address - Fax:605-990-3937
Practice Address - Street 1:1415 N SANBORN BLVD
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301-1015
Practice Address - Country:US
Practice Address - Phone:605-996-2020
Practice Address - Fax:605-990-3937
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD458152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD458OtherSTATE LICENSE
SD9202572Medicaid
SDU13736Medicare UPIN
SD9202572Medicaid