Provider Demographics
NPI:1629208038
Name:KRUOCH, ZANNA S (OD)
Entity Type:Individual
Prefix:
First Name:ZANNA
Middle Name:S
Last Name:KRUOCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2525 LUCAS DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-1804
Mailing Address - Country:US
Mailing Address - Phone:713-743-2020
Mailing Address - Fax:713-743-0963
Practice Address - Street 1:2525 LUCAS DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75219-1804
Practice Address - Country:US
Practice Address - Phone:214-528-7354
Practice Address - Fax:713-743-0963
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2010-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX07404T152WC0802X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL046010289Medicaid