Provider Demographics
NPI:1659361772
Name:KRUSE, DARYL L (OD)
Entity Type:Individual
Prefix:
First Name:DARYL
Middle Name:L
Last Name:KRUSE
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 1:5802 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:WI
Mailing Address - Zip Code:53406-4050
Mailing Address - Country:US
Mailing Address - Phone:414-955-2020
Mailing Address - Fax:414-955-6300
Practice Address - Street 1:5802 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:WI
Practice Address - Zip Code:53406-4050
Practice Address - Country:US
Practice Address - Phone:414-955-2020
Practice Address - Fax:414-955-6300
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2442035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38583600Medicaid
WI1659361772Medicaid
U22752Medicare UPIN