Provider Demographics
NPI:1629162482
Name:KRILEY, DAVID JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:JOHN
Last Name:KRILEY
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 1:35 PLAZA DRIVE
Mailing Address - Street 2:ROUTE 309 NORTH
Mailing Address - City:TAMAQUA
Mailing Address - State:PA
Mailing Address - Zip Code:18252-4450
Mailing Address - Country:US
Mailing Address - Phone:570-668-2672
Mailing Address - Fax:570-668-2683
Practice Address - Street 1:35 PLAZA DR
Practice Address - Street 2:RTE 309 NORTH
Practice Address - City:TAMAQUA
Practice Address - State:PA
Practice Address - Zip Code:18252-4405
Practice Address - Country:US
Practice Address - Phone:570-668-2672
Practice Address - Fax:570-668-2683
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2011-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOE005128T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA553634OtherNATIONAL VISION A
PA553634OtherNATIONAL VISION A
T28085Medicare UPIN