Provider Demographics
NPI:1255323952
Name:KOOGLER, KIRK JUSTIN (OD)
Entity Type:Individual
Prefix:DR
First Name:KIRK
Middle Name:JUSTIN
Last Name:KOOGLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:510 E SOUTHLAKE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6579
Mailing Address - Country:US
Mailing Address - Phone:817-481-1665
Mailing Address - Fax:817-329-7613
Practice Address - Street 1:510 E SOUTHLAKE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6579
Practice Address - Country:US
Practice Address - Phone:817-481-1665
Practice Address - Fax:817-329-7613
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-18
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5135TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00845YMedicare UPIN
TX8F0084Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER