Provider Demographics
NPI:1487640785
Name:COUSINEAU-KRIEGER, CHANTAL (MD)
Entity Type:Individual
Prefix:DR
First Name:CHANTAL
Middle Name:
Last Name:COUSINEAU-KRIEGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050W PERIMETER RD
Mailing Address - Street 2:
Mailing Address - City:JB ANDREWS
Mailing Address - State:MD
Mailing Address - Zip Code:20762-6601
Mailing Address - Country:US
Mailing Address - Phone:240-587-4928
Mailing Address - Fax:
Practice Address - Street 1:59TH MEDICAL WINGE GE
Practice Address - Street 2:2200 BERGQUIST DRIVE STE 1
Practice Address - City:LACKLAND AFB
Practice Address - State:TX
Practice Address - Zip Code:78236-9908
Practice Address - Country:US
Practice Address - Phone:240-505-2613
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN101061283A390200000X
IN01061283A207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program